Employment Application

Name (Last Name, First Name, Middle Initial)

Current Address (Street, Apt Number, City, State, Zip)

Mailing Address (Street, Apt Number, City, State, Zip)

Phone

Email

What is the best phone number and time frame to reach you?

Driver's License and State

Position applying for

Date you are available?

Desired Wage

Desired Shift (Day, Evening, NOC)

Are you currently employed? Are you currently employed? Yes No

Can we contact your current employer? Can we contact your current employer? Yes No

Are you legally authorized to work in the US? Are you legally authorized to work in the US? Yes No

Have you applied at Arlington Health and Rehabilitation before? Have you applied at Arlington Health and Rehabilitation before? Yes No

When did you previously apply?

Have you worked at Arlington Health and Rehabilitation before? Have you worked at Arlington Health and Rehabilitation before? Yes No

When did you work here?

Are you able to work overtime if required? Are you able to work overtime if required? Yes No

If No, please explain

Have you ever been found to have committed abuse? Have you ever been found to have committed abuse? Yes No

Have you ever pleaded "guilty" or been convicted of a crime? Have you ever pleaded "guilty" or been convicted of a crime? Yes No

If yes, please proved date(s) and details

CURRENT/PREVIOUS EMPLOYER (Name, City, & State)

Start Date

End Date

Starting Title

Ending Title

Immediate Supervisor

Phone Number

Employer/HR Email for verification

Reason for Leaving?

Summarize your job duties and responsibilities

May we contact this employer? May we contact this employer? Yes No Later

Explain any gaps in employment

EDUCATION - SCHOOL #1

Degree/Diploma

GPA

Major/Minor

School #2

Degree/Diploma

GPA

Major/Minor

Summarize and special training, skills, licenses and/or certificates

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

REFERENCES - Reference #1 Name

Relationship

Years acquainted

Phone

Email

Reference #2 Name

Relationship

Years acquainted

Phone

Email

Reference #3 Name

Relationship

Years acquainted

Phone

Email

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 Arlington Health and Rehabilitation 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, Arlington Health and Rehabilitation, 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 Arlington Health and Rehabilitation, 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 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 Arlington Health and Rehabilitation 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, Arlington Health and Rehabilitation, 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 Arlington Health and Rehabilitation, 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. l have read, fully understand, and accept all terms of the above Applicant Statement.

Applicant Signature

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