Application - Richmont Senior Living

Application for employment at:*

Notice to applicants

This community does not discriminate on the basis of age, gender, gender orientation, race, color or creed, religion, ancestry, national origin, genetics or disability other than those related to the ability to perform the job for which the applicant is being considered, or any other legally protected status. After a conditional job offer is extended, Nebraska law requires the community to perform a criminal background, sex offender, and registry checks on all direct care staff. It is the policy of this community to not hire direct care staff with criminal histories involving violence, abuse, neglect, or misuse of others’ property. State law requires every staff person to complete a health history screen. This application is current for ninety (90) days. If the applicant does not hear from this community in ninety (90) days and still desires to be considered for employment, it will be necessary to complete a new application. Dishonesty in completing this form is reason for immediate dismissal.

Applicants Information

Name*

First Middle Last

Current Address*

Street Address City State ZIP Code

Phone*

Email*

Position Applied For:*

Hours Desired*

Day
Evening
Night

Work Desired*

Full time
Part time
Temporary

Desired Wage:*

Wage Type*

Hourly
Salary

Have you previously worked for this community?

Yes
No

Dates

Referral Source:*

Are you over 18 years of age?*

Yes
No

Have you ever been convicted of a felony or misdemeanor?*

Yes
No

List any convictions and dates:

Employment History

Current Employer*

Dates Employed*

Address*

Phone*

Position/Title*

Name and Title of Supervisor*

Summary of Duties*

Reason for Leaving*

Starting Wage*

Current Wage*

Previous Employer*

Dates Employed*

Address*

Phone*

Position/Title*

Name and Title of Supervisor*

Summary of Duties*

Reason for Leaving*

Starting Wage*

Current Wage*

Training & Education

Highest grade completed:

Degree/diploma:

Other training:

Licenses/certification held:

Honors/extracurricular activities during school:

Other professional organizations, honors, and community involvement you feel contributes to your job qualifications:

Personal References:*

Name	Phone	Email	Relationship

Must include: 2 former supervisors, 2 former co-workers, 2 former residents and/or family members of residents for whom you’ve provided care. We ask that you contact these individuals and let them know we will be calling to speak with them.

Employment Agreement:

I give this community permission to contact previous employers and personal references and release from all liability all individuals or companies providing such information. I understand my employment and/or continued employment may be dependent upon the results of background checks. I understand my employment may be terminated for any dishonesty in completing this form.

Signature*