Wellsville Retirement Community

Career Application

Fields in bold required.

Position Applying For: Referral Source:

First Name: MI: Last Name:

Social Security Number: - -

Street Address:

City: State: Zip Code:

Day Phone: () - Evening Phone: () -

Email Address:

Are you at least 16 years of age?

Are you at least 18 years of age?

Are you able to perform the essential functions of the job for which you applied with or without reasonable accomodations?

Have you ever been employed with Wellsville Retirement Community in the past?

If yes, give dates:
From To Location

Do you have any relatives currently working for Wellsville?

If yes, give name, location and position

Are you able to work ...
Fulltime/Parttime?
*Evenings?
*Nights?
*Days?
*Weekends?
*Holidays?

On what date would you be available to begin work? (mm-dd-yyyy) - -

Can you travel if a job requires it?

Have you ever been convicted of a crime other than a routine traffic violation? (Conviction will not necessarily disqualify applicant from employment)

If Yes, give dates and circumstances.

Education

	Please print name, city & state for each school listed	Did you graduate?	Diploma / Degree
High School
College
Other

Special Skills and Qualifications

List equipment, machinery, special skills, and qualifications acquired from past employment experience.

List applicable professional or technical licenses or certifications relative to the position for which you are applying.

Employment Experience

Start with your present or most recent job. Include military service assignments.

1)

Past Employer	Job Title	Employment Dates
Address	Supervisor	Wage/Salary
Telephone 1	Duties and Responsibilities
Telephone 2	Reason for Leaving

2)

Past Employer	Job Title	Employment Dates
Address	Supervisor	Wage/Salary
Telephone 1	Duties and Responsibilities
Telephone 2	Reason for Leaving

3)

Past Employer	Job Title	Employment Dates
Address	Supervisor	Wage/Salary
Telephone 1	Duties and Responsibilities
Telephone 2	Reason for Leaving

4)

Past Employer	Job Title	Employment Dates
Address	Supervisor	Wage/Salary
Telephone 1	Duties and Responsibilities
Telephone 2	Reason for Leaving

References

1)

Reference Name

Telephone

2)

Reference Name

Telephone

I certify that answers given herin are true and complete to the best of my knowledge. I authorize investigations of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed six months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the employer.

If required, you will be informed prior to employment. I also understand that some positions require the examination of driving records prior to employment.

I understand that if hired by Wellsville Retirement Community my employment is at will and may be severed by either party at any time with or without cause. I understand that neither this document nor an offer of employment from Wellsville Retirement Community constitutes an employment contract unless a specific document to that effect is executed by the employer and employee in writing.

Signature: Date: 09/04/2010