Name

First Name

Last Name

Social Security #

Present Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Permanent Address (If different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Position Applied For

Rate of Pay Expected

Would you work full time

Yes

Would you work part time

Yes

Are you able to work

Days

Nights

Either

Do you currently hold any licenses/certification?

Yes

If yes, please list.

Special skills or qualifications you have which you feel are related to the position for which you are applying

Volunteer or Community Experience

Where you previously employed by us?

Yes

If yes, when?

Friends or Family member working for us

Have you ever been convicted of a crime

Yes

If Yes, describe in full

Date available, if hired

YYYY

Person to be notified in case of accident or emergency

Record of Education

Please list name and address of school and or college, course of study, last year completed, graduation date, diploma and/or degree obtained

Were you in U.S. Armed Forces?

Yes

If yes, what branch

Dates of duty

Rank at discharge amd military duties including special training

Personal References

(Names and contact information that are noot relatives or former employees)

Employment Record

List all present and past positions beginning with most recent. Please include Name and address of company, hire to end of employment dates, work you did there, starting and ending salary, and Name of Supervisor.

Have you ever been bonded

Yes

If yes, on what jobs?

May we contact employers listed above?

Yes

If yes, what jobs?

This institution does not discriminate in hiring or in any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination which relates to essential duties I would be required to perform.

I have applied for employment in a position at Trinity Station Retirement Community. I am requesting that the Kentucky State Police provide the employer with any record of conviction found in the files of the Kentucky centralized criminal history record information system. I know that I have the right to inspect my criminal history record and to request correction of any inaccurate information. If I do not exercise that right, I agree to hold harmless the Kentucky State Police and nay Kentucky State Police employee(s) from any claim for damages arising from the dissemination of inaccurate information.

I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity or eligibility for employment.

This type of employment State Law requires a criminal/fingerprint check as a condition of Emplymentt KRS 216.293. You will be asked for your driver's license and social security card to be copied and placed in your file should you be hired.

Type your full name if you understand and accept the above statement.

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