Last Name *
First Name *
Middle Name *
Address *
Street *
City *
State *
Zip *
Telephone *
Daytime Phone*
Evening Phone
Best Time To Contact You?
Social Security Number
Emergency Contact Information
Last Name
First Name
Middle Name
Contact Phone
Contact Email
1. Are you 18 years of age or older *
2. Do you have the right to work in the United States *
(If hired, you will have to show proof of identity and employment eligibility)
3. Have you ever been employed by Fallbrook Woods before *
If yes, give dates and position held:
4. Can you provide proof of immunization for the following diseases upon employment *
Measles, Mumps and Rubella *
Chicken Pox (Varicella) *
Hepatitis *
State law requires all employees working with residents to provide proof of immunization.
5. Do you have any relatives currently working for Fallbrook Woods *
If yes, please list:
6. Have you ever been terminated or forced to resign from any employment *
If yes, please explain fully:
7. Have you ever been convicted of, had adjudication withheld, pled nolo contendere, or pled guilty to
a misdemeanor or
felony criminal offense *
(Falsification or omission of this or any other information on this application is grounds for immediate termination. A conviction does not necessarily disqualify you from employment. The nature of the conviction, how long ago and the position for which you are applying are important.)(Falsification or omission of this or any other information on this application is grounds for immediate termination. A conviction does not necessarily disqualify you from employment. The nature of the conviction, how long ago and the position for which you are applying are important.)
If yes, please explain fully:
Job Interest:
Position Desired *
Date Available
Salary Desired ($)
per
Will you accept
Temporary or seasonal work
Full-time work
Part-time work
Other
Specify any days or hours NOT available for work
How did you learn about this opening
Educational History and Training
A. School/LocationB. Graduate? Y/NC. Degree, Diploma, or CertificateD. Field of study
A. List schools attended, starting with MOST RECENT.
Professional Certificates and Licenses
Type of Certificate or License
Certificate / License Number
Issued by what State
Expiration Date
Have you ever had, or do you currently have pending, any disciplinary action, suspension, or revocation taken by any licensing body or authority?
If yes please explain fully:
Experience: Beginning with the most recent, list in the following boxes your present and past employment.
All spaces MUST be completed. A resume may be used to supplement, not to substitute for, employment information.
Applicant Statement (Please read carefully)
I certify that all the information on this employment application, related employment papers, and all interviews are true and correct. Any misrepresentation by me will be sufficient for cancellation and/or separation from service
I understand that just as I am free to resign at any time, Fallbrook Woods reserves the right to terminate my employment at any time with or without cause and without prior notice, I also understand that no representative at Fallbrook Woods other than the president in writing, has authority to enter into any agreement contrary to the foregoing.
I understand that my employment is contingent upon satisfactory results in the screening and background investigation process, which may include a criminal background and/or abuse registry check, verification of my ability to perform the essential functions.
I authorize Fallbrook Woods to investigate all references and to secure additional information about me, if job related. I hereby release from liability Fallbrook Woods and its representatives for seeking such information and all other persons or corporations for furnishing such information. I hereby waive any rights or claims I may have whether presently fully developed or not, against Fallbrook Woods, or it's agents employers arising out of the release - authorized or unauthorized - of any information received pursuant to or in connection with the handling, processing, investigation of my application for employment. I authorize the release of any employment information about me to future employers.
If hired, I agree to conform to the policies and procedures of Fallbrook Woods and that the contents of the employee handbook or personnel manuals, as well as the policies and practices, are subject to change or modification by Fallbrook Woods, solely at it's discretion without notice. I understand and agree that it is my responsibility to be aware of such changes and modifications.
I understand that Fallbrook Woods is a drug-free workplace and it may require individuals who complete the initial employment screening process to submit to a drug screening program, which may include taking of urine and/or blood samples, and reserves the right to require that all employees submit to drug and alcohol testing during the course of their employment. I agree to consent to any applicable drug or physical examination and other employment-related test and further agree to hold Fallbrook Woods harmless for any claims resulting from such screening and testing for drug and/or alcohol use.
I understand that Fallbrook Woods is an Equal Opportunity Employer and does not discriminate in employment regardless of race, color, sex, religion, national origin, age, handicap, disability, marital status, or any other classification protected by law and that no question on this application is used for that purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by State or Federal law. I acknowledge and agree that if at anytime I am subjected to any type of discrimination or harassment, I will contact my Department Supervisor or the head of Human Resources immediately to obtain assistance in the resolution of such matters.
I hereby represent and warrant that I have read and fully understand the foregoing and seek employment understanding these conditions and of my own free will and in accordance with my own judgment.
I have have read and understood the above text: Date: 2012/02/05
We pride ourselves in the care we provide at Fallbrook Woods. We recognize that excellent care begins with our caring, compassionate staff. The residents are our top priority, and we choose staff who feel the same way. In exchange for your hard work as a member of our team, we offer opportunities for advancement, flexible scheduling and competitive wages. We're a small community of only 56 residents, which allows you to get to know each resident personally.
