Employment Application 1234567 PERSONAL INFORMATION We provide equal employment opportunities to all employees and applicants for employment with regard to race, color, ancestry, national origin, gender, sexual orientation, marital status, religion, age, disability, gender identity, results of genetic testing, or service in the military. Equal employment opportunity applies to all terms and conditions of employment, including hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation, and training. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors. Thank you for considering employment at Brookside Rehabilitation & Wellness. Please fill out this application completely in order to be considered for employment.Today's Date First Name* Middle Name Last Name* Address City State Zip code Cell Phone*Home PhoneEmail Employment ReferralHow were you referred to us? Walk-in Rehire Employee Advertisement Other Employment Referral Continued - If you were referred by an Employee, please provide the employee name. If you were referred from Advertisement, where did you find that?Have you applied to Brookside Inn (BSI), or Brookside Rehabilitation and Wellness (BRW) or have you been employed with either business previously? Yes No If yes, under what name? If yes, date of application or employment: Do you have any relatives employed by BSI or BRW? Yes No If yes, please give names and relationship: POSITION APPLYING FORLocation: Brookside Rehabilitation and Wellness Brookside Inn Position Applying For: Position status desired Full Time Part Time On-Call as Needed (PRN) Are you available to work: Days Nights Holidays Weekends If there are specific times when you cannot work, please explain:Date Available for Work: If employed, do you expect to be engaged in any additional business or employment outside of your job? Yes No If yes, please give details:EDUCATION/TRAINING Please List Name and Address of Schools you have attended:High School or GED: Diploma Yes No College or Universities: Diploma Yes No Subjects Studied: Vocational or Technical School: Certificate or Diploma? Yes No Subjects Studied: Additional Course Work: SPECIAL SKILLSWhat skills or additional training do you have that are related to the job for which you are applying?What machines and equipment can you operate that are related to the job for which you are applying?What computer and software system experience do you have that is related to the job for which you are applying?Are you presently employed? Yes No LICENSES / CERTIFICATESHave you ever held a professional license? (Even if it is not relevant to the position you are applying for.) Yes No Name on License: Type of License: License Number: State: Expiration Date: WORK EXPERIENCE Please list your work history within the past 10 years beginning with your most current/recent employer.Employer: Start Date: End Date: Address: City and State: Phone: Supervisors Name and Title: May we contact this supervisor? Yes No Your Job Title? Your duties:Reason for leaving:Employment 2Employer: Start Date: End Date: Address: City and State: Phone: Supervisors Name and Title: May we contact this supervisor? Yes No Your Job Title? Your duties:Reason for leaving:Employment 3Employer: Start Date: End Date: Address: City and State: Phone: Supervisors Name and Title: May we contact this supervisor? Yes No Your Job Title? Your duties:Reason for leaving:Employment 4Employer: Start Date: End Date: Address: City and State: Phone: Supervisors Name and Title: May we contact this supervisor? Yes No Your Job Title? Your duties:Reason for leaving: PROFESSIONAL REFERENCES Three references must be provided. No personal or relative references please.REFERENCE #1Relationship: Name and title: Company: Work PhoneCell PhoneREFERENCE #2Relationship: Name and title: Company: Work PhoneCell PhoneREFERENCE #3Relationship: Name and title: Company: Work PhoneCell Phone AFFIDAVIT, CONSENT, CERTIFICATION AND RELEASE: Please read the following statement carefully and acknowledge that you have read and agree to comply with it by providing the information requested below. I hereby certify that the facts set forth in this employment application (and accompanying resume if applicable) are true and complete to the best of my knowledge, and I agree and understand that any misrepresentation of information or failure to disclose information on this employment application may disqualify me from further consideration for employment and, if employed, may subject me to termination. I understand that in connection with my application for employment, I may be subject to a complete background check and drug screen if a conditional offer of employment is extended to determine my eligibility for employment. A positive drug screen or a failed background check will result in a withdrawal of the offer of employment. Brookside Communities comply with applicable Federal and state laws including the Fair Credit Reporting Act (FCRA) when conducting background checks. I understand that as a condition of employment, I may be required to provide proof of vaccinations, or obtain company provided vaccinations including a flu vaccination, in compliance with applicable laws. I understand that Brookside Communities require all associates to immediately disclose any exclusion, suspension or other event that makes me ineligible to participate in any Medicare or Medicaid program. I authorize Brookside Communities to obtain reference information on my work performance. I hereby release Brookside Communities from any and all liability at any time which could result from obtaining and making an employment decision based on such information. Finally, in the event I am employed, I understand I am required to abide by all company rules and regulations as a condition of employment. I also acknowledge this application is not a contract of employment and nothing herein should reasonably be construed as such. I do acknowledge that if employed, my employment will be "at-will," meaning either Brookside Communities or I may terminate the employment relationship at any time with or without cause. This company is a smoke-free workplace in compliance with state, local, and other applicable laws. DO NOT SIGN UNTIL YOU HAVE READ THE STATEMENT ABOVE. By my signature below, I certify that I have read, fully understand, and accept all terms of the foregoing statement. Please signify your acceptance by entering the information requested in the fields below. Signature: Typing your name will count as your legal signature of acceptance of the affidavit, consent, certification and release form.* Our company is committed to providing reasonable accommodation to individuals with disabilities. If, because of a medical condition or disability, you need a reasonable accommodation for any part of the employment and application process, please notify the Nursing Home Administrator.ResumeAccepted file types: pdf, Max. file size: 24 MB.Please attach your resume here. PDF files only.EmailThis field is for validation purposes and should be left unchanged. Contact Us Brookside Rehabilitation & Wellness1055 S Perry St. ~ Castle Rock, CO 80104(P) 303-688-3738(E) email@example.com Schedule a Tour FollowFollow Name First Last PhoneEmail Comments or questions:CAPTCHACommentsThis field is for validation purposes and should be left unchanged.