APPLICATION FOR EMPLOYMENT

EQUAL EMPLOYMENT OPPORTUNITY


Mary Wade will not, except if otherwise permitted or required by law, discriminate on the basis of race, color, religious creed, age, sex, marital status, sexual orientation, national origin, ancestry, present or past history of mental disorder, mental retardation, learning disability or physical disability or other protected status under state, federal, or local Equal Opportunity Laws with respect to making hiring and like decisions or other terms and conditions of employment. Mary Wade is a drug-free workplace. The Home does extensive testing of all employment candidates for substance abuse. Please answer ALL questions and print legibly.

 

GENERAL INFORMATION

(if less than three years at current address)

Previous Address

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If you are hired you will be required, within three days, to show proof of identity and authorization for employment in the United States. You will also be required to sign an I-9 Form, verifying, under oath, your employment authorization.


EMPLOYMENT RECORD


Starting with your most recent job; list all previous employers, including self-employment, summer and part-time jobs.

PLEASE DO NOT WRITE "SEE RESUME"

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EDUCATION


 


REFERENCES


Please list name, address and phone number(s). Do not include friends or relatives.

 

REFERENCE 1

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REFERENCE 2

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REFERENCE 3

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ACKNOWLEDGEMENT


PLEASE READ BEFORE SIGNING

If you have any questions regarding this statement, please ask them of an employment interviewer before signing.

It is my understanding that Mary Wade will make a thorough investigation which will include a verification of my entire work history, and the verification of all data given in this application. I authorize such an investigation and the giving and receiving of any information by the Home. I am aware that I have a right to make a written request as to the nature and scope of this investigation. I release from liability any person giving or receiving such information.

In the event of my employment by Mary Wade, I will comply with all rules and regulations as set forth in the Home’s policy manual or the communication distributed by the Home to all employees. I understand that if I am hired, my employment with the Home will be "at will" and may be terminated by the Home or me at any time for any reason or for no reason. I understand that no documents or statements of the Home will constitute a contract or employment that in any way limits the Home’s rights to terminate my employment “at will.” I further understand that the “at will” nature of my employment cannot be changed except by a formal written contract signed by the Administrator of the Home.

I certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers, and that the responses given are true, complete and accurate to the best of my knowledge and are made in good faith. Without limiting the “at will” status of my employment if I am hired, I understand that if any of the statements on this application are untrue my employment will be terminated immediately.

I understand that Federal law prohibits the Home from hiring or retaining an employee who has been found guilty of patient abuse, neglect, or mistreatment by a court of law or who has had an adverse finding entered against him/her in the nurse’s aide registry. If it is discovered, subsequent to hire, that I have been untruthful about my history of patient abuse, neglect, or mistreatment, I will be subject to immediate discharge.

I authorize all the educators, agencies and employers listed in this application to furnish the Home with information regarding my education, employment history, or any other matter related to my application for employment with the Home.

I understand that this is an application for employment, and that no employment contract is being offered. I further understand that if employed, such employment is for no definite period of time and the Home can change wages, benefits, and conditions of employment at any time.

I have read and understand the above:


CRIMINAL BACKGROUND


NOTE: THIS PORTION OF THE APPLICATION WILL ONLY BE REVIEWED BY MEMBERS OF THE HUMAN RESOURCES DEPARTMENT (OR THE PERSON(S) IN CHARGE OF EMPLOYMENT) AND ANYONE INVOLVED IN INTERVIEWING THE APPLICANT.

Applicants are not required to disclose the existence of an arrest, criminal charge or conviction for which records have been "erased." The types of records subject to erasure under Connecticut law are as follows:


(a) a finding of delinquency or that a child was a member of a family with service needs; (b) a sentence as a youthful offender; (c) a criminal charge that was dismissed or "nolled;" (d) a criminal charge for which the person was found not guilty; and (e) a conviction for which the person received an absolute pardon.

Any applicant whose criminal records were erased will be considered to have never been arrested and may so swear under oath.

I understand that the information provided above will not necessarily result in the rejection of my application, but that the nature of the information will be considered as it relates to the performance of the job duties in question and in light of the requirements of state and federal law.


PRE-EMPLOYMENT PHYSICAL EXAMINATION & DRUG TESTING RELEASE FORM


In order to ensure the safety and well being of all our employees, we have devised a physical examination that helps to ensure that all potential employees are physically capable of handling the type of work that he/she may be required to perform. Included in this physical examination are tests for substance. 

 

I,

do hereby consent to undergo a drug/alcohol test, as required by Mary Wade, (employer). Further, I authorize the hospital, clinic and/or testing facility to release to Mary Wade, (employer) the results of such test and I release the hospital, clinic, and/or testing facility, its doctors, and medical personnel from liability from any release or use of this information.

Further, I release Mary Wade, its officers, directors, employees and agents, in both their individual and representative capacities, from any liability in connection with the physical examination and related tests.

Please indicate, by your signature below, that you have read this form and are aware of that the testing procedures are for.


EEO APPLICANT DATA FORM


IMPORTANT INFORMATION FOR ALL APPLICANTS:

To enable the Home to meet government reporting regulations and to maintain an Affirmative Action Plan, applicants are requested to complete this personal data sheet.

INFORMATION WILL BE USED FOR GOVERNMENT REPORTING PURPOSES AND WILL BE DETACHED AND KEPT SEPARATE FROM JOB APPLICATION. This information will not be used as selection criteria and will be treated as personal and confidential. Your decision or refusal to provide the requested information will not subject you to any adverse treatment. Your voluntary cooperation will be appreciated.

If any of these definitions apply to you, please check off the appropriate box or boxes to be considered under our Affirmative Action Plan.

I qualify as a Special Disabled Veteran because I am:

A veteran who is entitled to compensation (or who, but for receipt of military retirement pay, would be entitled to compensation) under laws administered By the Veteran’s Administration for a disability:

I qualify as a Veteran of the Vietnam Era because I am a person who served more than 180 days of active military, naval, or air service, any part of which was during the period of August 5, 1964 through May 7, 1975

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