Eastern Star Masonic Home

APPLICANT INFORMATION

First Name *:

Last Name *:

M.I. :

Date :

Street Address *:

Apartment / Unit #:

City *:

State *

Zip *:

Phone *:

E-mail Address *:

Date Available :

Desired Salary $:

Position Applied for *:

Shift(s) Desired :

Have you ever worked for this company? YES NO

If so, when?

Have you ever been convicted of a felony? YES NO

If yes, explain

EDUCATION / PROFESSIONAL LICENSES AND CERTIFICATIONS

High School *:

Address *:

From *:

To *:

Did you graduate? YES NO

Degree :

College :

Address :

From :

To :

Did you graduate? YES NO

Degree :

Other

Address :

From :

To :

Did you graduate? YES NO

Degree :

License / Certificate Type :

State :

Number :

Date Issued :

License / Certificate Type :

State :

Number :

Date Issued :

REFERENCES

Please list three professional references who are not related to you.

Full Name :

Affiliation :

Company :

Phone :

Full Name :

Affiliation :

Company :

Phone :

Full Name :

Affiliation :

Company :

Phone :

PREVIOUS EMPLOYMENT

Starting with your most current &/or most recent employment. This section must be completed by the applicant and NOT substituted by a resume. A resume can be submitted in addition to this application.

Company :

Phone :

Address :

Supervisor :

Job Title :

Starting Salary $ :

Ending Salary $ :

Responsibilities :

From :

To :

Reason for Leaving :

May we contact your previous supervisor for a reference? YES NO

Company :

Phone :

Address :

Supervisor :

Job Title :

Starting Salary $ :

Ending Salary $ :

Responsibilities :

From :

To :

Reason for Leaving :

May we contact your previous supervisor for a reference? YES NO

Company :

Phone :

Address :

Supervisor :

Job Title :

Starting Salary $ :

Ending Salary $ :

Responsibilities :

From :

To :

Reason for Leaving :

May we contact your previous supervisor for a reference? YES NO

OTHER

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state?
YES NO

If yes, explain :

Eastern Star Masonic Home is required to complete a criminal record and dependent adult abuse check on all potentialemployees. If your answer is “yes,” you will not automatically be disqualified from employment consideration, except as required by state or federal law.

HOW DID YOU HEAR ABOUT US?

Were you referred to Eastern Star? YES NO

If yes, who referred you? :

Did you see this position advertised? YES NO

If yes, where? Indeed.com, Eastern Star’s Website, Newspaper or Other Site: :

DISCLAIMER AND SIGNATURE

I certify that all statements made in this application (and accompanying resume, if applicable) are true and accurate to the best of my knowledge and that I have not knowingly omitted any relevant material. I understand that any material omission or misrepresentation will result in my disqualification from consideration for employment or, if discovered after I begin employment with Eastern Star Masonic Home may result in my termination.

I hereby authorize release of information for purposes of this application. I hereby authorize Eastern Star Masonic Home to contact the references listed as well as the current/former employers listed and discuss my professional and/or work-related qualifications, my character and fitness for the position for which I am applying. I hereby authorize persons, schools, my current employer (if applicable) and previous employers or other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment. I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that a comprehensive background check will be conducted to determine my eligibility for hire. This may include, but is not limited to, criminal records check, child abuse/dependent abuse registry check, and sex offender registry. I also understand that a physical examination may be required for certain positions. 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 physical examination which relates to the essential duties I would be required to perform.

I hereby release Eastern Star Masonic Home and other persons or entities from any claims or liability that may arises or based on the decision to conduct a reference and/or background check.

I understand that, if hired, my employment is considered to be at will and can be terminated by either party at any time with or without cause. Eastern Star Masonic Home reserves the right to terminate without any notice. I understand that this application and any other handbook or documents which I may receive does not constitute a contract of employment with Eastern Star Masonic Home. I acknowledge that any offer of employment is conditional and may be withdrawn at any time.

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

I certify that I have read, fully understand, and accept all terms as noted above.

Employment Application

Employment Form