Waverly Heights, Ltd.

Waverly Heights, Ltd.

Waverly Heights, Ltd. Online Application
We consider applicants for all positions without regard to race, color, religious belief, national origin, age, marital or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.
Job Information
All Fields Must be fully completed.
Date of Application:
Position(s) Applying For:
Referral Source:
Name of Referral:	(N/A if Walk-In)
Personal Information
First Name:		Last Name:
Street address:
Address cont:
City:
State:
Zip code:
Telephone:
Social Security #:
Email:
Have you lived in the State of Pennsylvania for the past two (2) consecutive years?: Yes No
If "No", where did you live?
Have you filed an application here before? Yes No
If "Yes", give date:
Have you ever been employed here before? Yes No
If "Yes", give date:
Are you employed now?	Yes No
If "Yes", may we contact your present employer? Yes No
Please list any relatives employed by Waverly Heights, Ltd:
Are you legally authorized to work in the United States? Yes No
On what date would you be able to start working?
Are you available to work: (Check all applicable options.)
Full Time: Part Time: Temporary:
Day Shift: Evening Shift: Night Shift:
Are you available to work weekends, overtime hours or holidays if required? Yes No
If "No", please explain why.
Employment Experience
Start with your present or last job. Include military service and volunteer activities. You may exclude organization names which indicate race, color, religion, national origin, handicap or other protected status.
Employer:
Street address:
Address(cont.):
City:
State:
Zip code:
Telephone:
Dates Employed	From: To:
Position Held:
Hourly/Salary Rate	Starting $: Ending $:
Supervisor's Name:
Work Performed:
Reason for Leaving:
Job #2
Employer:
Street address:
Address(cont.):
City:
State:
Zip code:
Telephone:
Dates Employed:	From: To:
Position Held:
Hourly Rate/Salary:	Starting $: Final $:
Supervisor's Name:
Work Performed:
Reason for Leaving:
Job #3
Employer:
Street address:
Address(cont.):
City:
State:
Zip code:
Telephone:
Dates Employed:	From: To:
Position Held:
Hourly Rate/Salary:	Starting $: Final $:
Supervisor's Name:
Work Performed:
Reason for Leaving:
Job #4
Employer:
Street address:
Address(cont.):
City:
State:
Zip code:
Telephone:
Dates Employed:	From:To:
Position Held:
Hourly Rate/Salary:	Starting $: Final $:
Supervisor's Name:
Work Performed:
Reason for Leaving:
May we contact these employers? Yes No
Special Skills & Qualifications
Summarize special skills and qualifications acquired from employment or other experience:
Have you a history or conviction for a violent crime? Yes No
Have you ever been dismissed from employment due to abuse of clients or residents? Yes No
Have you been charged/convicted of a crime in the past 10 years? (Conviction will not necessarily disqualify applicant from employment) Yes No
If "Yes", please explain:
Education
School Name:	High School University/College
Years Completed:
High School:	9 10 11 12
University/College:	1 2 3 4
Diploma/Degree(s):
Describe Course of Study:
Describe specialized training, apprenticeship, skills, extracurricular activities and graduate studies completed:
Affidavit
I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire, or if hired, dismissal. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information. If employed, I agree to conform to Waverly Heights rules and regulations and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to at any time with adequate prior notice to me. I further acknowledge that my employment may be terminated and any offer of employment or my acceptance of an employment offer, if such is to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of Waverly Heights or myself. I also understand that all Waverly Heights employees are classified as probationary for the first 90 days of continuous service.
I agree with the above. I do not agree with the above.