Job Application - Shepherd Premier Senior Living

Shepherd Premier Senior Living

Employment Application

Thank you for your interest in working for the Shepherd Premier Senior Living Team. Please complete the entire application below then email a copy of your resume to both patti@shepherdresidentialcare.com and michele@shepherdresidentialcare.com

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Today's Date

Full Name

Date of Birth

Street Address

City

State

Zip Code

Phone

___________

Date Available

Social Security No.

Desired Pay

Position Applied For

Driver's License Number & State

How Were You Referred to Us?

Are You a Citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company?

Yes No

If yes, when?

Have you ever been convicted of a felony?

Yes No

If yes, explain:

Please summarize your Special Skills, Qualifications, Certifications, etc:

___________

Education Information

High School

Address

From:

To:

Did You Graduate?

Yes No

Diploma:

College:

Address

From:

To:

Did You Graduate?

Yes No

Degree:

Other:

Address

From:

To:

Did You Graduate?

Yes No

Degree:

___________

References

Please list three professional references and let them know in advance we will be contacting them. Please do not include relatives. Your application will not be considered unless three references are provided.

Full Name

Relationship:

Company

Phone:

Address:

___________

Full Name

Relationship:

Company

Phone:

Address:

___________

Full Name

Relationship:

Company

Phone:

Address:

___________

Work History

Company:

Phone

Address:

Supervisor

Job Title

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes No

___________

Company:

Phone

Address:

Supervisor

Job Title

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes No

___________

Company:

Phone

Address:

Supervisor

Job Title

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Yes No

___________

Military Experience

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

___________

As a condition of employment, all employees must be Bondable and Insurable. Are you at least 19 years of age?

Yes No

List ALL States and Counties of Residence and Employment for the past 7 years:

Have you had any moving traffic violations?

Yes No

If yes, please describe:

Have you EVER been charged or convicted of a felony and/or a misdemeanor or served time?

Yes No

If yes, please describe the incident, city & state and charge in full:

Have you EVER been accused, charged or convicted of any form of abuse, neglect or theft?

Yes No

If yes, please explain in detail:

Have you ever been a charged perpetrator or appeared on any sex offender or child abuse registry in the last 5 years?

Yes No

___________

I certify that my answers are correct and complete, and true to the best of my knowledge and belief.

I understand that the use of illegal drugs is prohibited during my employment and that additional testing for the presence of illegal drugs may be required prior to employment and randomly at any time during employment with Shepherd Residential Care Homes. I am willing to submit to drug testing to detect the use of illegal drugs.

I understand that any false or misleading information, omissions or misrepresentations of facts in my application or interview will result in the rejection of this application or discharge at any time during my employment. I authorize Shepherd to contract with Stateline Investigations to conduct a background check to verify any of this information including, but not limited to, criminal history and motor vehicle driving records.

I authorize all persons, companies and law enforcement authorities to release any information concerning my background and hereby release all said persons, companies and law enforcement agencies from any liability for any damage whatsoever for issuing this information. I release Shepherd companies, Shepherd Capital and Stateline Investigations from any liability which might result from making such investigations.

Signature (type your full name below):

Date:

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Shepherd Premier Senior Living

Employment Application

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