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Employment Application Form

Episcopal SeniorLife Communities


505 Mount Hope Avenue - Rochester, NY 14620
Name:
 
First Name
Middle Initial
Last Name
Date:
Address:
City:
State:
Zip:
Home Phone:
Cell/Pager/Message Number:
Email Address:
Nursing, Professional License and Certification that specifically relate to the position for which you are applying (including type an dlicense number):
Expiration Date:
Position or type of work desired:
Location desired (check all that apply):
Beatrice Place
Center For Rehabilition
River Edge Manor
Seabury Woods
Brentland Woods
Episcopal Church Home
Rockwood Center
 
Available to work:
Full Time
Part Time
Per Diem
Shift Preference:
When would you be available to start?:
Based on your work history, knowledge and skills relevant to the job for which you are applying, please briefly explain why you believe you are suitable for this position.
Were you previously employed by any program of Episcopal SeniorLife Communities:
If Yes, please give dates:
From:
To:
ESLC has a “Personal Relationships in the Workplace” policy under which family members/individuals in close personal relationships are prohibited from working in the same supervisory reporting line. If hired by ESLC in the position for which you are applying, are you aware whether you would be in a position within such a reporting relationship with a family member/individual in a close personal relationship?
(A “yes” answer is not an automatic bar to employment, but will put ESLC on notice that this policy may be implicated.)
If “Yes,” please provide the name(s) and, if known, the job title(s):

Education


School
Name and Address
Last Year Attended
Diploma/Degree/Course of Study
High School
1
2
3
4
College
1
2
3
4
Other Special Training That Specifically Relates to the Position for Which You are Applying
1
2
3
4
School of Nursing (provide information only if this is a requirement for the position for which you are applying)
1
2
3
4
Have you ever been convicted of a crime that has not been expunged, sealed, pardoned, annulled, statutorily eradicated, dismissed, or committed as a youthful offender?

(A “yes” answer is not an automatic bar to employment. Each situation is considered on its individual merits. Factors such as the nature of and age at time of offense, documentation relating to rehabilitation efforts, and the lapse in time since the offense will be considered. A conviction which is substantially related to the functions or qualifications of the position for which you are applying are also taken into consideration.)

If “Yes,” please describe fully the criminal conviction(s), listing the date(s), the nature of the offense(s), and your rehabilitation since the conviction(s):

Employment Experience


Please list all previous employers, starting with your current employer.


Employer:
Dates:
From:
To:
 
 
(Month/Year)
(Month/Year)
Address:  
 
Base Rate of Pay:
Per:
Phone:
Your Position:
 
Supervisor Name:
Reason for leaving:
Description of primary responsibilities:
 

Employer:
Dates:
From:
To:
 
 
(Month/Year)
(Month/Year)
Address:  
 
Base Rate of Pay:
Per:
Phone:
Your Position:
 
Supervisor Name:
Reason for leaving:
Description of primary responsibilities:
 

Employer:
Dates:
From:
To:
 
 
(Month/Year)
(Month/Year)
Address:  
 
Base Rate of Pay:
Per:
Phone:
Your Position:
 
Supervisor Name:
Reason for leaving:
Description of primary responsibilities:
 

Employer:
Dates:
From:
To:
 
 
(Month/Year)
(Month/Year)
Address:  
 
Base Rate of Pay:
Per:
Phone:
Your Position:
 
Supervisor Name:
Reason for leaving:
Description of primary responsibilities:
 

Employer:
Dates:
From:
To:
 
 
(Month/Year)
(Month/Year)
Address:  
 
Base Rate of Pay:
Per:
Phone:
Your Position:
 
Supervisor Name:
Reason for leaving:
Description of primary responsibilities:
 

Employer:
Dates:
From:
To:
 
 
(Month/Year)
(Month/Year)
Address:  
 
Base Rate of Pay:
Per:
Phone:
Your Position:
 
Supervisor Name:
Reason for leaving:
Description of primary responsibilities:
 
Professional References

Please do not list friends or family members.

Name
Address/Phone
# Years Known
Nature of Relationship
Applicant Statement Section

With regard to my current employer, Episcopal SeniorLife Communities May May Not contact my current employer.

I certify that all information on this application is accurate and complete to the best of my knowledge. I understand and agree that any misrepresentation, omission, false or incomplete statement by me may cause Episcopal SeniorLife Communities to eliminate me from further consideration for employment, or, if hired, to immediately terminate my employment, whenever it is discovered.

I hereby authorize Episcopal SeniorLife Communities or its agents to verify all statements contained in this application and/or my resume to the extent permitted by federal, state or local law. To the extent permitted by federal, state, or local law, I release all parties from any liability arising out of this provision and the use of such information. I understand that any offer of employment is contingent upon complying with Episcopal SeniorLife Communities requirements, including but not limited to, executing a separate Consent and Authorization(s) to conduct a background check.

I understand that all employment with Episcopal SeniorLife Communities is on an at-will basis, unless otherwise prohibited by state law, which means that, if hired, either I or Episcopal SeniorLife Communities can terminate the employment relationship at any time, for any reason, with or without cause or advance notice. I further understand that nothing in this employment application can be considered an offer or contract of employment. I further understand that no representation, whether oral or written, by any representative of Episcopal SeniorLife Communities at any time, can constitute a contract of employment, unless stated in a written agreement signed by the Human Resources Manager of Episcopal SeniorLife Communities.

I agree to comply with and acknowledge the procedures, policies and practices of Episcopal SeniorLife Communities in accordance with applicable law. I understand that Episcopal SeniorLife Communities and the benefit plan administrators and insurance companies, if applicable, have the maximum discretion under the law to administer, interpret, modify, discontinue, enhance, or otherwise modify policies, practices, benefits, or other terms and conditions of employment.

If hired, I understand that proof of authorization to work in the U.S. will be required in accordance with applicable law. I further understand, if hired, Episcopal SeniorLife Communities may request that I execute other documents (including, but not limited to, agreements regarding training, trade secrets, confidential information and conflicts of interest).

I understand that if offered employment, my employment with Episcopal SeniorLife Communities may be subject to any or all of the following, depending on the job position and applicable law: successful completion of a post-offer/pre-employment drug test, a review of references, a consumer report/background check, and collection and review of other background information including criminal conviction information and credit performance history, all in accordance with applicable law. I understand that I may be required to complete necessary consent forms in order for Episcopal SeniorLife Communities to conduct post-offer/pre-employment background checks and/or a pre-employment drug test. I understand that Episcopal SeniorLife Communities recommends that I do not resign my current job until satisfactory post-offer, pre-employment check results are received.

NEW YORK APPLICANTS ONLY: I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF ARTICLE 23-A OF THE NEW YORK CORRECTION CODE CLICK HERE IF MY POSITION WILL REQUIRE A CRIMINAL BACKGROUND CHECK TO BE CONDUCTED AS A CONDITION OF EMPLOYMENT.
I authorize Episcopal SeniorLife Communities to verify the accuracy of the information provided on this application and to obtain reference information on my work experience. I hereby release Episcopal SeniorLife Communities, and any party supplying references, from any liability for an employment decision based on such information.

 

With regard to my current employer, Episcopal SeniorLife Communities:
contact my current employer.



I understand that failure to reveal any prior employer, or giving false or misleading information on any part of the application (or any other accompanying or required documents) can be the basis for refusal to hire, or grounds for termination from Episcopal SeniorLife Communities.

 

Applicant Signature

By checking the “I Agree” box and entering my full name, email address, and today’s date below, I declare that I have read and agree to the above statements. I understand that by typing my full name below, I am electronically signing this application, and that my electronic signature has the same effect as if I had physically signed the application with a pen.

I Agree   

 

To sign this application, please type your name: Date :
Email Address:


 
Click here to submit this application.