Valley View Retirement Community. Enhancing Senior Lifestyles. Belleville, PA.

PERSONAL DATA

* Required fields

*Last Name

*First Name

*Middle Initial

*Social Security#

*Telephone#

Email

*Address Street Number

*City/Town

*State

*Zip

Have you worked under any other name? If yes, please indicate

JOB INFORMATION

*Position Applied For

Shift Preference

Salary/Wage Desired

Other Positions of Interest

Full-time

Part Time

Are there hours during the day that you would not be able to work at VVH?

Are you willing to work overtime and weekends?

GENERAL INFORMATION

*Were you previously employed by Valley View Retirement Community? Yes No

If so, when

In what department

Supervisor

If you are under the age of 18, can you provide proof of eligibility to work?

*Have you ever been convicted of a felony during the past five years?

*What prompted you to apply with us?

Advertisement Friend Walk In

Employment Agency Relative Other

I was referred by the following Valley View Retirement Community Employee

YOUR EDUCATION

	School Attended City/State	Years Completed	Graduate	Major/ Degree
Elementary
High School
College
Trade
Graduate
Other Special Training
Volunteer?

Licenses Held Type

State

Lic. #

Exp. Date

EXPERIENCE

Please provide information covering your complete employment experience. Be accurate and account for all of your time.
Use the comments area at the end of this section on EXPERIENCE to account for any gaps in your employment (most recent first).

*Are you presently employed?

*May we contact your present employer?

If not, why?

(Complete this section if you have served in the Armed Forces)

Period of Active Duty From

To

Describe your major duties and any special training

Name of Company

Address

Telephone#

From

To

Salary Starting/Ending

Supervisor

In detail, describe the work you did:

Reason for Leaving

Name of Company

Address

Telephone#

From

To

Salary Starting/Ending

Supervisor

In detail, describe the work you did:

Reason for Leaving

Name of Company

Address

Telephone#

From

To

Salary Starting/Ending

Supervisor

In detail, describe the work you did:

Reason for Leaving

Please give comments and/or other information on your experience, abilities
or affiliations you have been involved in which you believe would assist us in evaluating your qualifications:

*REFERENCES

Give name, address and telephone number of three references who are not related to you and are not previous employers:

ACKNOWLEDGMENTS

I understand that all statements made are subject to verification by Valley View Retirement Community. I give permission to Valley View Retirement Community to make any investigation of my personal or employment history and authorize any former employer, person, firm, corporation, credit agency, or government agency to give Valley View Retirement Community any information they may have regarding me without liability. In exchange for the review of this employment application by Valley View Retirement Community, I release all providers of information from any liability as a result of furnishings and receiving information.

I agree that, if employed, my conduct will conform to the rules and regulations established by Valley View Retirement Community and understand that my employment can be terminated at any time, with or without cause, and with or without notice at the option of either Valley View Retirement Community or me. I do not have any guarantee, if employed, of continued employment.

I understand that any employee or personnel manuals, handbooks or policies that may be distributed or announced to me during the course of my employment shall not be interpreted as a contract(s), and that all statements or representations made in any personnel policy manual or employee handbook are subject to change at any time by Valley View Retirement Community.

I further understand that, if I am hired, the first three months of my employment will be a probationary period, and that I must satisfactorily complete a three month period of probationary employment.

I certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that any false statements on this application shall be considered sufficient cause for disqualification from further consideration for employment, and if I am employed, for discharge of employment.

My signature on this application certifies that I have no history of or conviction for violent crime and was never dismissed from employment due to abuse of clients or residents.

*Signature

*Today's Date

I have read the above acknowledgments and understand their contents.

EMPLOYMENT APPLICATION

PERSONAL DATA

* Required fields

JOB INFORMATION

GENERAL INFORMATION

YOUR EDUCATION

EXPERIENCE

*REFERENCES

ACKNOWLEDGMENTS