Personal Information

Name (Full Legal)

Prior Names Used

Email

Present Address

Home Phone

Cell Phone

Position and shift desired

Rate of pay expected

Title and Number of license of certification (CNA, CMA, RN, LPN, or other)

Are you legally eligible for employment in the United States?

—Please choose an option—YesNo

If you are under 18 years of age, can you provide age verification.

—Please choose an option—YesNo

(Employment subject to minimum legal age verification.)

How did you learn of this opening?

Are you available to work:

—Please choose an option—Full-timePart-timeTemporary

Have you worked for us before?

—Please choose an option—YesNo

If yes, when?

On what date would you be available to work?

Are you related to or friends with any Parkside Homes, Inc., employees? If so, whom?

Are you aware of any reason you cannot perform the functions of the job for which you are applying?

—Please choose an option—YesNo

Describe:

Have you ever been convicted of a crime?

—Please choose an option—YesNo

If yes, explain:

Are you now under pending investigation or charges of violation of criminal law?

—Please choose an option—YesNo

If yes, explain:

Have you ever been debarred, excluded, or otherwise ineligible from participation in a Federal or State Health Care Program?

What did your prior job(s) consist of?

Special Skills & Qualifications

Summarize special job-related skills, training, foreign languages and qualifications acquired from employment or other experience that would especially fit you for work with our organization:

Previous Employment

Name & Address of Company & Type of Business:

Began working there in:

Finished working there in:

Hourly Starting Wage:

Hourly Ending Wage:

Reason for Leaving:

Describe the work you did:

Name of Supervisor:

Telephone:

Name & Address of Company & Type of Business:

Began working there in:

Finished working there in:

Hourly Starting Wage:

Hourly Ending Wage:

Reason for Leaving:

Describe the work you did:

Name of Supervisor:

Telephone:

Name & Address of Company & Type of Business:

Began working there in:

Finished working there in:

Hourly Starting Wage:

Hourly Ending Wage:

Reason for Leaving:

Describe the work you did:

Name of Supervisor:

Telephone:

Name & Address of Company & Type of Business:

Began working there in:

Finished working there in:

Hourly Starting Wage:

Hourly Ending Wage:

Reason for Leaving:

Describe the work you did:

Name of Supervisor:

Telephone:

I hereby give permission to contact the employers listed above concerning my prior work experience.

State any additional information you feel may be helpful to us in considering your application:

Education

Graduate School

College

Business/Trade/Technical School

High School

Elementary School

References

Name/Relationship

Address

Telephone Number

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I understand the following: 1) a pre-employment drug screen will be completed, 2) a result of “negative” must be achieved as a condition of employment, and 3) a refusal to submit to a drug test is considered as not completing the hiring process and the applicant will not be considered for future employment.

I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant:

Typing your name here signifies a "digital signature."

Date