Full Name (First, Middle, Last)
Full Street Address (Street, City, State, and Zip)
Position Applied For:
Direct Care StaffCNA/MALVN/RNResidential CoordinatorQIDPOther
Date you can start work: (Example: 01/01/2018)
Type of Employment you are seeking:
Full TimePart Time
Are you willing to work weekends/holidays?
Are you eligible to work in the United States? (Proof of eligibility will be required upon employment)
Do you have relatives or friends who currently work here?
If yes, please provide name and relationship:
Have you ever been employed by any entity of Mountain Shadows?
If yes, please provide dates of employment and positions held:
Have you ever filed an application with us before?
If yes, give approximate date: (Example: 01/01/2018)
This job requires you to be 18 years of age or older. Are you 18 years of age or older?
This job may require you to lift 50 pound independently. Are you able to do this?
This job requires you to read, write, and speak English. Are you able to do this?
Indicate the number of years of formal education:
Please list your most recent employers beginning with your present or last employer. Please provide all information requested. Do not write "see resume".
Please do not list former employers or relatives.
Compliance with the facility’s Substance Abuse Policy is a condition of employment. Employment is contingent upon successfully completing a urinalysis test/screen in accordance with facility policy. Continued employment is contingent upon compliance with the facility’s Alcohol and Drug Abuse Policy.
I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the facility shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me on the application. I also understand and agree that unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
During our initial or subsequent processing of your application for employment, a reference inquiry may be made which will provide applicable information concerning character, general reputation and personal characteristics. We may also verify such data as dates of employment and reasons for leaving previous employers. Omissions or misstatements of material facts may be considered cause for dismissal.
I authorize the release of any information regarding my employment or scholastic records and hereby release from liability, Mountain Shadows and its representatives from seeking such information and all persons, corporations, or organizations furnishing such information.
Signature - Please type your First and Last Name
By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. By providing your electronic signature and clicking submit you are agreeing to the terms and conditions of employment.