Employment Application

Personal Data

Will you be able to provide proof of eligibility for employment in the United States at time of hire? YES   NO

Have you ever been bonded? YES   NO   Unsure

Have you ever been refused bond? YES   NO   Unsure

Have you ever applied for a job with us before? YES   NO

Have you ever worked for us before? YES   NO

Are you related to any employee here? YES   NO

Are you related to any resident here? YES   NO

Have you ever been convicted of a crime except a minor traffic violation?
YES   NO

Has a finding ever been made against you for neglect or abuse of adults?
YES   NO

Have you ever been discharged or requested to resign from a position?
YES   NO

Have you ever held a position of trust (handling money or confidential material)?
YES   NO

Education

HIGH SCHOOL

Name and Location of school:

Highest grade completed:   Did you graduate? YES   NO

College, Trade, or Technical School

Name and Location of school:

Major:    Degree:

Date of Graduation

Name and Location of school:

Major:    Degree:

Date of Graduation

Are you taking any courses at present? YES   NO

Job Details

Position(s) applied for:

Note: Full-time and Part-time Plus are benefit eligible positions

How soon can you report to work?

Salary Requirements: per

Days of the week you cannot work:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are there any shifts you cannot work? YES   NO

How were you referred?
Newspaper Ad
Current Employee  Name:
Walk-In
Other  Please Specify:

Prior Work Record

Begin with most recent employer and complete in full. Include military service.

Employer Name:

Employer Phone:

Address:

Immediate Supervisor's Name and Position:

Starting Salary: Ending Salary:

Dates of Employment - From:    To:

May we contact this employer? YES   NO

Employer Name:

Employer Phone:

Address:

Immediate Supervisor's Name and Position:

Starting Salary: Ending Salary:

Dates of Employment - From:    To:

May we contact this employer? YES   NO

Employer Name:

Employer Phone:

Address:

Immediate Supervisor's Name and Position:

Starting Salary: Ending Salary:

Dates of Employment - From:    To:

May we contact this employer? YES   NO

Employer Name:

Employer Phone:

Address:

Immediate Supervisor's Name and Position:

Starting Salary: Ending Salary:

Dates of Employment - From:    To:

May we contact this employer? YES   NO

Employer Name:

Employer Phone:

Address:

Immediate Supervisor's Name and Position:

Starting Salary: Ending Salary:

Dates of Employment - From:    To:

May we contact this employer? YES   NO

Personal References

Please do not list relatives or previous supervisors

CERTIFICATION OF APPLICATION

I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize the past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, credit and financial history and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. By submitting this application online, it will be considered as if it were an original signature.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between WILLIAMSBURG LANDING, INC. and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon WILLIAMSBURG LANDING, INC. unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that WILLIAMSBURG LANDING, INC. retains the same right.

I agree to submit to a physical examination and/or substance abuse screen upon a conditional offer of employment and I understand my becoming employed and/or my continued employment are subject to the results, if any, of any physical examination and/or substance abuse screen in accordance with company policies and procedures and state/federal regulations. I also understand that the examining physician may ask questions regarding my current health condition, health history, health insurance claim and workers' compensation claim history, and that all such information will be retained by the examining physician in his/her confidential medical files, to be released only in accordance with federal and state law.

I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time.

I understand that this application will be kept on active file for 60 days from the date completed, after which time I would have to reapply in accordance with established company procedures.

DEPARTMENT OF SOCIAL SERVICES
DIVISION OF LICENSING PROGRAMS
SWORN DISCLOSURE STATEMENT

To the Applicant:
Section 63.2-1720 of the Code of Virginia requires that any person desiring work at a licensed assisted living facility or licensed adult day care center provide the hiring facility or center with a sworn disclosure statement or affirmation disclosing any criminal convictions or pending criminal charges, whether within or outside the Commonwealth of Virginia.

The law prohibits licensed assisted living facilities and licensed adult day care centers from hiring any individuals convicted of the following: murder or manslaughter, malicious wounding by mob, abduction, abduction for immoral purposes, assaults and bodily woundings, robbery, carjacking, threats of death or bodily injury, felony stalking, sexual assault, arson, drive by shooting, use of a machine gun in a crime of violence, aggressive use of a machine gun, use of a sawed-off shotgun in a crime of violence, pandering, crimes against nature involving children, incest, taking indecent liberties with children, abuse and neglect of children, failure to secure medical attention for an injured child, obscenity offenses, possession of child pornography, electronic facilitation of pornography, abuse and neglect of incapacitated adults, employing or permitting a minor to assist in an act constituting an obscenity or related offense, delivery of drugs to prisoners, escape from jail, felonies by prisoners; or an equivalent offense in another state. However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired if five years has elapsed since the conviction.

Any person making a false statement on this form regarding any criminal offense shall be guilty of a Class 1 misdemeanor.

Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law? YES   NO

Are you the subject of any pending criminal charges? YES   NO

I hereby affirm that the information provided on this form is true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment offered by this facility. I understand that all information on this form is subject to verification.

Applicant's Signature: ___________________________ Date: ______________

NOTE TO LICENSEE: This form must be retained for all compensated employees.