Application – Wood-Lawn, Inc.

WOOD-LAWN HEIGHTS EMPLOYMENT APPLICATION

Applicant,

We appreciate you taking the time to consider Wood-Lawn Heights as a prospective employer. To help us serve you better, please fill out the application in its entirety. Do not leave any blanks.

If you are accepted for a position to be employed at Wood-Lawn Heights, you will be expected to adequately pass the following (per nursing home regulations):

At Your Cost:

Criminal Background Check ($22.00, unless a federal background check must be done, it is $38.50) will be deducted from your first paycheck.

At Our Cost:

TB Skin Test

Drug Test

Reference Check

All employees of Wood-Lawn Heights are employed on an “at will” basis. This means employees have the right to terminate their employment at any time, for any reason, and Wood-Lawn Heights can also terminate the employment at any time with or without cause and with or without notice. All policy statements, procedures, manuals, or documents as well as statements by an employee or representative shall not in any way modify this at will status.

Thank you for your time,

Wood-Lawn Heights Management

Application

CONFIDENTIAL

Date of Application *

PERSONAL INFORMATION

Legal Name *

Legal Name

First

Middle

Last

Current Address *

Primary Phone *

Alternate Phone

Email *

Date of Birth *

EMPLOYMENT DESIRED
(RN, LPN, CNA, OFFICE, ACTIVITIES, DIETARY, ENVIRONMENTAL)

Which of our sites are you interested in? *

First Choice

Type *

Shift *

Salary *

Second Choice

Type *

Shift *

Salary *

Third Choice

Type *

Shift *

Salary *

Will you accept employment of: *

Full Time?

Part Time?

Are you currently employed?: *

Yes

Part Time

Other

May we contact your current employer?: *

Yes

Are you 18 or older?: *

Yes

Have you previously been employed with Wood-Lawn?: *

Yes

If so, when?

How did you learn of this opening?

EDUCATION

High School:

College:

Vocational / Business:

Professional Education:

Lab / X-Ray Training:

Provide any other information that you deem important reguarding your education or work experience:

Member of Professional Organizations:

If applying for business office, please list GPA:

Were you ever in the U.S. Armed Forces?

Yes

If so, what branch?

Dates of Duty:

PROFESSIONAL LICENSES AND/OR CERTIFICATION

EMPLOYMENT RECORD
(LIST LAST OR PRESENT POSITION FIRST)

Employer

Dates Employed

Salary Range

Address

City / State / Zip

Positions and Dutys

Supervisor

Phone

Reasons for Leaving

Employer

Dates Employed

Salary Range

Address

City / State / Zip

Positions and Dutys

Supervisor

Phone

Reasons for Leaving

Employer

Dates Employed

Salary Range

Address

City / State / Zip

Positions and Dutys

Supervisor

Phone

Reasons for Leaving

If your former employment references, education, or military experience are under another name other than indicated on front of application, please indicate below:

First

Middle

Last

Have you ever been convicted of a crime?

Yes

If so, for what, when and where?

According to Arkansas Law 20-33-203, conviction of certain specified crimes will result in an applicant being permanently banned from working in a long-term facility.

PERSONAL REFERENCES
LIST AT LEAST TWO PERSONAL REFERENCES NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

Name

First

Last

Address

Phone

Years Known

Name

First

Last

Address

Phone

Years Known

EMPLOYMENT UNDERSTANDING
(PLESE READ AND SIGN)

This institution does not discriminate in hiring or any other decision based on race, color, sex, citizenship, national origin, ancestry, veteran status, or based on age or physical or mental disability unrelated to the ability to perform the work required. No question, this application is intended to secure information to be used for such discrimination.

Please initial the following statements:

Initial

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such an investigation and release from all liability all persons, companies or corporations supplying such information.

Initial

I understand that my employment is “At Will,” and that either party is free to terminate the employment relationship at any time without cause.

Initial

I understand that if I am employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.

Initial

I understand that if I quit in the first two weeks of being employed, I will be paid.

Initial

My signature attests to the fact that the information provided on this application is true and correct and that my employment may be terminated for any misstatement or omission of fact.

Signature

Date

AVAILABILITY RECORD

Primary position desired

Will you accept another position?

If so, what?

Are you available to work:

Weekends

Holidays

Rotating Shifts

PAYROLL DEDUCTION AUTHORIZATION

I agree to have the cost of the background check, $22.00 or $38.50, if a federal background check had to be ran, deducted from my paycheck, in part or in whole, until the full amount is paid.

Name *

Name

First

Middle

Last

Date *

EMPLOYMENT REFERENCE CONSENT AND RELEASE

Applicant Name *

Applicant Name

First

Middle

Last

I hereby give consent to all prior employers of mine, or my current employer, to provide the information below regarding my employment with the prior or current employers to Wood-Lawn, Inc.

This consent is valid for a period of six (6) months from the date indicated below. A copy of this form shall serve as an original.

Signature *

Signature

First

Middle

Last

Date *

If you are human, leave this field blank.