Employment Application





Personal Details

Full Name*

Present Address*

City*

State*

Zip Code*

Phone Number*

How long at present address?*

Resident of NC for 5 or more years?

Former States of Residence

Social Security Number*

Birth Date*

Have you ever been convicted of a crime?

If Yes, Explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Position Details

Position applying for

Salary Desired

Shifts Available (Most positions require Every Other Weekend to be worked)*

Have you applied with us before?*

If Yes, When?

Have you ever been employed with us before?

If Yes, When?

Employment desired*

Are you presently employed?*

When would you be available for work?*

Education

High School

Name of High School:

Location of High School (Complete mailing address)

Number of completed years in High School

Type of High School Degree

College

Name of College

Location of College (Complete mailing address)

Number of completed years in College

Major & Degree

Business/Trade School

Name of Business/Trade School

Location of Business/Trade School (Complete mailing address)

Number of years completed in Business/Trade School

Major & Degree

Professional School
Name of Professional School

Location of Professional School (Complete mailing address)

Number of years completed in Professional School

Major & Degree

References

Please list two references other than relatives or previous employers.

Reference 1

Name*

Address*

Telephone*


Reference 2

Name*

Address*

Telephone*

Work Experience

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Employer 1

Name of Employer

Complete Address

Phone Number

Name of last supervisor

Employed From

Employed to

Starting pay or salary

Final pay or salary

Your last job title

Reason for leaving (be specific)


Employer 2

Name of Employer

Complete Address

Phone Number

Name of last supervisor

Employed From

Employed to

Starting pay or salary

Final pay or salary

Your last job title

Reason for leaving (be specific)


Employer 3

Name of Employer

Complete Address

Phone Number

Name of last supervisor

Employed From

Employed to

Starting pay or salary

Final pay or salary

Your last job title

Reason for leaving (be specific)


Employer 4

Name of Employer

Complete Address

Phone Number

Name of last supervisor

Employed From

Employed to

Starting pay or salary

Final pay or salary

Your last job title

Reason for leaving (be specific)


Employer 5

Name of Employer

Complete Address

Phone Number

Name of last supervisor

Employed From

Employed to

Starting pay or salary

Final pay or salary

Your last job title

Reason for leaving (be specific)


May we contact your present employer?*

Did you complete this application yourself?*

If not, who did?

Applicant Understanding

PLEASE READ CAREFULLY

By signing this document, you are agreeing that you have reviewed the following consumer disclosures and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time.

I agree

In exchange for the consideration of my job application by Memory Care of the Triad (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Memory Care of the Triad or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Ownership of the Company. Both the undersigned and Memory Care of the Triad may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits or hours. I understand that should my employment be terminated before 90 day probationary period is completed, the fee for the two TB tests($15.00ea), Drug Test ($37.00), and Background Check($10.00) Total of $77.00 will be deducted from final paycheck received from Memory Care of the Triad. Employee may receive copy of TB test for a fee of $10.00. I understand that if I am employed, MCT makes an investment in time and training to train me. If I accept an offered position, I will be here on time and as scheduled. Should you resign within the first 16 days of employment, your pay rate will be reduced to the Federal Minimum Wage. Also by your signature, you understand that a two (2) week notice is required should you resign. Failure to do so will invoked the North Carolina Law that states we may reduce your final pay check to the Federal Minimum Wage. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for post testing after any injury during my employment and at any time during employment that my work, behavior, or physical condition is questionable while on duty; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application, the Company will request an investigative report including information as to my criminal background. By my signature below, I understand that a Criminal Background Check will be completed in accordance with the requirements of this state and my opportunities for employment is conditional based on this review. I further understand that my employment with the Company shall be probationary for a period of Ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. Once the 90 days is completed, a permanent position will be extended if all training requirements are met satisfactory.

Signature (Full Name)*

Date *

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

By signing this contract you agree to all of the above and promise to always do your best.

Signature (Full Name)*

Date*

Employment Notice

ALL EMPLOYEES AT MEMORY CARE OF THE TRIAD ARE REQUIRED TO HAVE A TWO STEP TB FOR EMPLOYMENT. EACH APPLICANT IS REQUIRED TO BRING A COPY OF THEIR FIRST TB FROM THE HEALTH DEPARTMENT, PHYSICIAN, PRIMECARE OR OTHER HEALTH CARE FACILITY OF CHOICE, BEFORE STARTING EMPLOYMENT. THE TB HAS TO BE GIVEN NO MORE THAN TWO WEEKS PRIOR TO EMPLOYMENT AT BRADFORD VILLAGE.

MEMORY CARE OF THE TRIAD WILL INCUR THE EXPENSE OF THE TB TEST.

THE SECOND TB TEST (STEP TWO) WILL BE GIVEN WITHIN 14 DAYS OF EMPLOYMENT AND THE NURSE FOR MEMORY CARE OF THE TRIAD WILL TAKE CARE OF THE PROCEDURE.

MEMORY CARE OF THE TRIAD WILL INCUR THE EXPENSE OF THE SECOND TB TEST.

IF YOU HAVE A TB THAT HAS BEEN GIVEN WITHIN EMPLOYMENT WITH ANOTHER HEALTHCARE FACILITY AND THERE HAS NOT BEEN A BREAK IN EMPLOYMENT, WE CAN ACCEPT A COPY OF THAT TB FROM YOUR CURRENT EMPLOYER.
Signature (Full Name) *

Date*

If you would like Memory Care of the Triad to give the first TB, check this box:

Job Description Acknowledgement

I have read the job description for my position that I will hold at Bradford Village/Memory Care and I have asked questions that may need to be answered and have understanding of the job duties that will be expected if employment is offered.

Signature (Full Name)*

Date*