Employment Application

This is the online application for Somerset Court, you may also download the application HERE and mail it in or bring it to our directors personally.

Name: *
Name:
Date You Can Start: *
Date You Can Start:
$
Area of employment: *
Refered By: *
Select All That Apply
Permanent Mailing Address: *
Permanent Mailing Address:
Home Phone: *
Home Phone:
Emergency Contact:
Emergency Contact:
Emergency Contact's Phone:
Emergency Contact's Phone:
(A conviction will not necessarily bar you from employment, failure to disclose will.)
Type of work you are available for: *
Shifts you are willing to work: *
(Select all appropriate shifts)
Please Complete All Sections of the Employment History
"See resume" should not be substituted for any section of this application
1. Current or Most Recent Employer:
Employer:
Employer:
Address
Address
Phone:
Phone:
SuperVisor
SuperVisor
From Date:
From Date:
To Date:
To Date:
$
$
2. Employer Immediately Preceding #1
Employer:
Employer:
Address:
Address:
Phone:
Phone:
Supervisor:
Supervisor:
From Date:
From Date:
To Date:
To Date:
$
$
3. Employer Immediately Preceding #2
Employer:
Employer:
Address:
Address:
Phone:
Phone:
Supervisor:
Supervisor:
From Date:
From Date:
To Date:
To Date:
$
$
References
Reference #1:
Reference #1:
Phone:
Phone:
Address:
Address:
Reference #2:
Reference #2:
Phone:
Phone:
Address:
Address:
Reference #3:
Reference #3:
Phone:
Phone:
Address:
Address:
Reference #4:
Reference #4:
Phone:
Phone:
Address:
Address:
Questions:
(Complete if applying for Care Services)
Questions:
(Complete if applying for Housekeeping Services)
Questions:
(Complete if applying for Food Service)
Questions:
(Complete if applying for Maintenance Service)
Background Check and Release:
Name:
Name:
Current Address:
Current Address:
Prior Address #1:
Prior Address #1:
If you have not lived at the above address for at least five (5) years, please list all former addresses you have lived during the past five (5) years:
Prior Address #2:
Prior Address #2:
Prior Address #3:
Prior Address #3:
My signature below certifies that I have completed this Application and that all information provided is true and correct to the best of my knowledge and belief. In connection with this background information request of me by my current/prospective employer. I authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to information about my employment, consumer credit history, education, criminal background, and driving history to the individual representing my current or prospective employer and his agent. I understand the investigation into my background may include but not be limited to, safety, driving record, related inquiries, arrest and criminal record inquiries, financial disclosure, fingre printing and credit history inquiries. I also understand that the inquiry into my background will be made before any employment offer is made. Any misrepresentation or omission of any facts in my application, resume, or other materials or during any interviews can be justification of refusal of employment or, if employed, termination. I also understand my employment and compensation can be terminated with ot without cause or notice, at any time, at the option of either the company or myself. Finally, I understand that the first six (6) months of my employment is probationary and is a period intended to determine my qualifications for the duties I have been hired to perform.
Electronic Signature: *
Electronic Signature:
Date of Signing: *
Date of Signing:
Somersetcourtassistedliving@gmail.com