Willowbend at Marion | Healthcare and Rehabilitation

Facility you are applying to:

Date of application *

Personal lnformation

Full name *

First and Last

Email

Current address *

Telephone *

How did you hear about us?

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Position Desired

Position applying for *

When can you start? *

Can you work any shift?

Yes

No

If no, what shift can you work?

Are you under 18 years of age? *

Yes

No

If yes, do you have a work permit?

Yes

No

In process of obtaining

Have you ever been convicted of a crime? *

Yes

No

If yes, please explain the offense, the date and the place.

Conviction of a criminal offense will not necessarily prevent your employment.

Have you ever applied to this company before? *

Yes

No

If yes, when?

Have you ever worked for any facility affiliated with the Elder Outreach company, including Louisiana facilities Southwind, Encore, Pelican Pointe, Eastridge, and The Broadway OR Arkansas facilities Encore, Willowbend, Pleasant Valley, and Three Rivers? *

Yes

No

If yes, when?

Who was your supervisor?

Reason for leaving:

Please list any friends or relatives currently working at the facility you are applying to:

Can you perform the functions of the job for which you are applying with or without reasonable accommodations? *

Yes

No

If no, please explain:

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Education

Please select the highest level achieved: * Please select the highest level achieved:

If other, please specify

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Professional License or Certificate

Type of license:

State issued in:

Expiration date:

Has your license ever been suspended?

Yes

No

If yes, please explain when and why.

(Will not necessarily prevent employment)

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Employment Record

Please list most recent employer *

Date started *

Date of last day *

Currently Work Here

Final DayFinal Day

Job title *

Supervisor *

Work / duties performed *

Hourly rate / salary *

Reason for leaving *

Please list previous employer *

Date started *

Date ended *

Job title *

Supervisor *

Work / duties performed *

Hourly rate / salary *

Reason for leaving *

Please list previous employer *

Date started *

Date ended *

Job title *

Supervisor *

Work / duties performed *

Hourly rate / salary *

Reason for leaving *

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References

Please provide three work-related references not related to you. If work-related references are not available, teachers, clergy, or other personal references may also be submitted.

Reference 1: Name *

Reference 1: Relationship *

Reference 1: Company name (if applicable)

Reference 1: Email

Reference 1: Address

Reference 1: Phone *

Reference 1: Years acquainted *

Reference 2: Name *

Reference 2: Relationship *

Reference 2: Company name (if applicable)

Reference 2: Email

Reference 2: Address

Reference 2: Phone *

Reference 2: Years acquainted *

Reference 3: Name *

Reference 3: Relationship *

Reference 3: Company name (if applicable)

Reference 3: Email

Reference 3: Address

Reference 3: Phone *

Reference 3: Years aquainted *

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You may include a filled out print application or CV.

Employment Understanding and Acknowledgement

I understand that any employment by this community will be on a three (3) month basis. If employed by Elder Outreach, I agree to abide by its rules and regulations. I understand that this community will check the references provided in this application, including former employers, supervisors and schools. I give authorization to these individuals, companies, and schools to furnish information and I release from all liability or responsibility this community, all persons, companies or corporations releasing or using this information.

I understand that I will be required to submit other background related information so that various background checks can be conducted. I may also be required at any time to submit to employment physical examinations, drug tests, health screes as per community policy. I give authorization to the community to have access to this information.

I understand that I must produce a driver’s license, social security card or other documents proving my identity and right to work in the United States.

I certify that all information disclosed on this application is true and accurate. I understand that my employment is at will, and either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement of omission of fact appearing on this application.

We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status.

Do you understand and agree? *

Yes, I understand

Electronic Signature *

Enter Full Name, Date

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Job Application

We invite you to apply for the Willowbend Team by completing an employment application.

Application for Employment

Personal lnformation

Position Desired

Education

Professional License or Certificate

Employment Record

References

Employment Understanding and Acknowledgement

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