Employment | Chuckanut Ridge Assisted Living

If #2 #3

Name

Address

Mailing

Phone

Email

Best Phone

Drivers License

Position Applying For

Dates Available

Desired Wage

Desired Shift

Are you currently employed?

Yes
No

If so, may we contact your current employer?

Yes
No

Are you legally authorized to work in the US?

Yes
No

Have you applied at Chuckanut Ridge before?

Yes
No

If yes, when did you previously apply?

Have you worked at Chuckanut Ridge before?

Yes
No

If yes, when did you work here?

Are you able to work overtime if required?

Yes
No

Have you ever been found to have committed abuse?

Yes
No

Have you ever pleaded "guilty" or been convicted of a crime?

Yes
No

Current Employer

Start Date

End Date

Starting Title

Ending Title

Immediate Supervisor

Immediate Supervisor Phone Number

Employer/HR Email For Verification

Reason For Leaving?

Summarize your job duties and responsibilities

May we contact this employer?

Yes
No
Later

Explain any gaps in employment

EDUCATION

Degree / Diploma

GPA

Major / Minor

School #2

School #2 Degree

School #2 GPA

School #2 Major / Minor

Summarize any special training, skills, licenses and/or certifications

List any additional qualifications or information about yourself that is pertinent to your desired position

REFERENCES

Reference #1 Relationship

Reference #1 Years

Reference #1 phone

Reference #1 email

Reference #2 - Name

Reference #2 relationship

Reference #2 years

Reference #2 phone

Reference #2 email

Reference #3 Name

Reference #3 Relationship

Reference #3 years

Reference #3 phone

Reference #3 email

APPLICANT STATEMENT *

l have read, fully understand, and accept all terms of the below Applicant Statement.

I declare under penalty of perjury under the laws of the state of Washington that all information I have provided in order to apply for and secure work with Chuckanut Ridge is true, complete, and correct. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered. I expressly authorize, without reservation, Chuckanut Ridge, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. l hereby waive any and all rights and claims I may have regarding Chuckanut Ridge, its agents, employees, or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me. l understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. If l am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. I understand that I am an at-will employee. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

Applicant Signature *

Today's Date *

Employment Application

Employment Application