Applicant's Contact Information:

Full Name (required)

Email (required)

Phone Number (required)

Mailing Address (required)

City (required)

State / Province (required)

Postal Code (required)

Employment - Careers / Jobs:

What position(s) are you applying for? (required)
('Shift + Click' all that apply)
---Accounting AssistantAccounting SpecialistAssistant AdministratorCaregiverCommunity RepresentativeCommunity Resource DirectorCookDietary ManagerExecutive Director / AdministratorFood Service / DishwasherHousekeeperIn-Home Care DirectorIn-Home Care ProviderLifestyles CoordinatorMaintenance / Grounds KeeperReceptionistRegional Director of Sales and MarketingRegional Director of OperationsRegistered Nurse / Director of WellnessVan DriverVolunteering

What type of work are you applying for? (required)
('Shift + Click' all that apply)
---Regular full-time workRegular part-time workTemporary work

What communities / cities are applying your for? (required)
('Shift + Click' all that apply)
---Bend Villa Retirement ( Bend, Oregon )Bridgewood Rivers Assisted Living ( Roseburg, Oregon )Deerfield Village Assisted Living ( Milwaukie, Oregon )Emerald Valley Assisted Living ( Eugene, Oregon )Inland Point Assisted Living ( North Bend, Oregon )Inland Point Senior Estates ( North Bend, Oregon )Jefferson Manor ( Dallas, Oregon )Meadow Creek Village Assisted Living ( Salem, Oregon )Oak Lane Retirement ( Grants Pass, Oregon )Parkland Senior Estates ( Mcminnville, Oregon )Parkland Village Assisted Living ( Mcminnville, Oregon )Spring Valley Assisted Living ( Springfield, Oregon )

If hired, on what date can you start? (required)

What days and hours are you available for work? (required)

Can you work on the weekends? (required)
 Yes No

Can you work evenings? (required)
 Yes No

Are you available to work overtime? (required)
 Yes No

If hired, would you have transportation to and from work? (required)
 Yes No

What Salary / Wage do you desire? (optional)

Have you ever applied to (and / or) worked for our company before? (required)
 Yes No

If yes, explain / include date(s).

Do you have any friends, relatives, or acquaintances working for our company? (required)
 Yes No

If yes, enter the full name of the person(s) and describe the nature of your relationship(s).

Employment Eligibility:

Are you over the age of 18? If under 18, hire is subject to verification of minimum legal age. (required)
 Yes No

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? (required)
 Yes No

If hired, are you willing to submit to and pass a controlled substance test? (required)
 Yes No

ADA Accommodations:

Are you able to perform the essential functions of the position(s) for which you are applying - without reasonable accommodation? (required)
 Yes No

If no, describe the functions that cannot be performed.

(Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants / employees to perform essential functions. It is possible that a hire may be tested on skill / agility and may be subject to a medical examination conducted by a medical professional.)

Criminal History:

Have you ever been convicted of a criminal offense, felony, or misdemeanor? (required)
 Yes No

If yes, please describe the crime(s), state nature of the crime(s), when and where convicted and disposition of the case(s).

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Education, Training and Military:

Did you graduate High School? (required)
 Yes No

If yes, what High School - include Graduation Year / City / State.

Did you graduate College / University? (required)
 Yes No

If yes, what College / University - include Degree Earned / Graduation Year / City / State.

Did you graduate Trade / Vocational School? (required)
 Yes No

If yes, what Trade / Vocational School - include City / State.

Did you serve in the Military? (required)
 Yes No

If yes, what Branch / Rank / Total Years / Skills and Duties in the Military.

Additional Experience, Training, Qualifications and Skills:

Do you speak, write or understand any foreign languages? (required)
 Yes No

If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us? (required)
 Yes No

If yes, please describe and explain.

Employment History:

Are you currently employed? (required)
 Yes No

Employment - Present or Last:

Employer's Name (required)

Employer's Address / City / State (required)

Supervisor's Name (required)

Supervisor's Phone (required)

Supervisor's Email (optional)

Length of Employment - include dates (required)

Your Job Title (required)

Your Responsibilities / Duties (required)

Your Salary / Wage (optional)

Reason for Leaving (required)

May we contact this employer for references? (required)
 Yes No

Employment - Previous:

Employer's Name (required)

Employer's Address / City / State (required)

Supervisor's Name (required)

Supervisor's Phone (required)

Supervisor's Email (optional)

Length of Employment - include dates (required)

Your Job Title (required)

Your Responsibilities / Duties (required)

Your Salary / Wage (optional)

Reason for Leaving (required)

May we contact this employer for references? (required)
 Yes No

Employment - Previous:

Employer Name (required)

Employer's Address / City / State (required)

Supervisor's Name (required)

Supervisor's Phone (required)

Supervisor's Email (optional)

Length of Employment - include dates (required)

Your Job Title (required)

Your Responsibilities / Duties (required)

Your Salary / Wage (optional)

Reason for Leaving (required)

May we contact this employer for references? (required)
 Yes No

Professional References:

References Name / Title / Phone / Email (optional)

Other:

How were you referred to our company / website? (required)

Message (optional)

Read and agree to the terms below:

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company.

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.

I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

I have read and agree to the terms above. (required)
 Yes No

Your Initials (required)

Today's Date (required)
"YYYY/MM/DD"

Type the Code Below (required)