UA-86915696-1

Employment

Application For Employment
Dayspring Senior Living, Inc.

Equal Opportunity Employer: Our Company does not discriminate on the basis of race, color, religion, sex, national origin, age, marital or veteran status, disability, or any other status protected under applicable law. You may request a reasonable accommodation in order to participate in the application process. Please contact Doug Adkins at Dayspring Senior Living, Inc. to request a reasonable accommodation.

NAME AND ADDRESS
Your Name (required)

Your Email (required)

Social Security Number

Street Address

City

State

Zip Code

Home Phone Number

Alternative Phone Number

Emergency Contact

Phone Number

Relationship

POSITION DESIRED
Position applied for:

Desired Hours:Full TimePart Time

Salary Expected:

Date Available:

Are you available to work whatever schedule is necessary to help us meet our corporate objectives and client obligations?
YesNo
If no, what days are you available?SundayMondayTuesdayWednesdayThursdayFridaySaturday
What hours are you available?8am-12pm12pm-4pm4pm-8pm8pm-12am12am-4am4am-8am

PERSONAL INFORMATION
Are you presently employed?YesNo
If yes, may we contact your present employer?YesNo
Do you have reliable transportation to get to work each day?YesNo
If no, please explain.
To your knowledge, have you ever been employed by this company?YesNoIf yes, when?
Position:
Reason for leaving?
Names and relationships of relatives or acquaintances employed by this company:

Referral Source

EDUCATION
THE FOLLOWING INFORMATION WILL BE USED ONLY TO THE EXTENT RELEVANT TO THE QUALIFICATIONS AND POSITION FOR WHICH YOU APPLY.
Highest grade completed:

Do you have a high school diploma or GED?YesNo
Did you earn a degree from college?YesNo
If yes, name of college:
Degree:
Year awarded:

PERSONAL HISTORY
Have you ever been convicted of, or plead guilty or "no contest" (nolo contendere) to a misdemeanor or felony? (Do not include minor traffic infractions for which you never appeared in court, offenses which were dismissed or discharged after completion of successful probation, and convictions or pleas which have been deemed sealed, annulled, or expunged by law)?YesNo
If yes, give details concerning the type of crime, the date of the conviction or plea, the penalty imposed, and any other circumstances you deem relevant to a full understanding of what occurred.
NOTE: Answering "Yes" to this question is not an automatic bar to employment. Factors such as age at the time of the offense, seriousness, and nature of the violation, relatedness to the job sought, the amount of time which has passed since the event occurred, and evidence of rehabilitation will be taken into account. However, please be advised that a misstatement or omission in answering this question may be grounds for disciplinary action, including discharge.

Have you been arrested or charged with any misdemeanor or felony not disclosed above for which you are out on bail or free on your own recognizance pending disposition or trail (again, do not include minor traffic infractions for which no court appearance is necessary?)YesNo
If yes, give the date(s) and details of the arrest or charge and any other circumstances you deem relevant to a full understanding of what occurred. NOTE: Answering "Yes" to this question is not an automatic bar to employment. We will consider whether the circumstances of the arrest or charge substantially relate to the circumstances of the particular job sought, and other considerations allowed by law. Again please be advised that a misstatement or omission in answering this question may be grounds for disciplinary action, including discharge.

Have you ever been sued in a civil action with regard to the death or personal injury or intentional damage to any person or to any property?YesNo
If yes, give details concerning the nature of the claims and defenses raised by the parties, the outcome of the action (e.g., settlement, jury verdict, or other disposition), and any other circumstances you deem relevant to a full understanding of what occurred.

Are you legally eligible for employment in the Country?YesNo
Are you currently engaged in using illegal drugs?YesNo

WORK HISTORY
Have you ever been granted a military or government security clearance?YesNo
If yes, level of clearance:

Do you have any special job skills or qualifications that may be relevant to the position for which you are applying?YesNo
If so, please describe:

List all employment, including military, for the past seven (7) years beginning with your present or last job held.

Employer:

From: To: Salary:

Address:

City:

State:

Zip code:

Supervisor: Phone:

Job Title:
Reason for Leaving:
Job Duties:

_____________________________________________________________________________________________________________

Employer:

From: To: Salary:

Address:

City:

State:

Zip code:

Supervisor: Phone:

Job Title:
Reason for Leaving:
Job Duties:

_____________________________________________________________________________________________________________

Employer:

From: To: Salary:

Address:

City:

State:

Zip code:

Supervisor: Phone:

Job Title:
Reason for Leaving:
Job Duties:

______________________________________________________________________________________________________________

Employer:

From: To: Salary:

Address:

City:

State:

Zip code:

Supervisor: Phone:

Job Title:
Reason for Leaving:
Job Duties:

_____________________________________________________________________________________________________________

Employer:

From: To: Salary:

Address

City:

State:

Zip code:

Supervisor: Phone:

Job Title:
Reason for Leaving:
Job Duties:

Explain any gaps in your employment.

Have you ever been dismissed or asked to resign from employment?YesNo

If yes, provide a brief explanation, including the name of the employer, approximate date, and any relevant circumstances:

REFERENCES
Please list the names, addresses, and phone numbers of five (5) people who are not related to you and who are not former employers:
1: Name Occupation
Address Phone

2: Name Occupation
Address Phone

3: Name Occupation
Address Phone

4: Name Occupation
Address Phone

5: Name Occupation
Address Phone

UNDERSTANDINGS AND AGREEMENTS

Please read carefully:

I certify that all of the facts and information contained in the application or any other written documents I have submitted are true and complete, and I understand that any misrepresentation, falsification or omission of this application or other written documents I have submitted shall be sufficient reason for refusal to hire or, if discovered after employment has begun, dismissal of my employment.

I hereby authorize investigation of all matters contained in this application, as well as my statements and information contained in other written documents I have submitted for consideration of employment. All third parties (including, but not limited to, individuals, schools, businesses, former employers, law enforcement authorities, governmental or licensing agencies and consumer reporting bureaus) are authorized to disclose any and all requested information to this prospective employer. I agree to release all third parties, as well as Dayspring Senior Living, Inc., its owners, directors, officers, and employees, from any claims arising out of actions taken under these authorizations. I also authorize the procurement of a consumer report by Dayspring Senior Living, Inc. as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for the Town to procure consumer reports at any time during my employment period.

I agree that if the results of such investigation or consumer report are not satisfactory, any offer of employment may be withdrawn, or, if applicable, my employment may be terminated immediately. I agree to conform to and adhere to the rules and regulations governing my employment.

Further, I understand and agree that this application and any other materials I may receive are not intended to be, nor shall they be construed to be a contract of employment, and that my employment and compensation may terminate, with or without cause, and with or without notice, at any time, at the option of either myself or my employer.

Signature of Application Date: