LOUISVILLE CARE COMMUNITY - APPLICATION FOR EMPLOYMENT
  1. All information will be treated confidentially. Your application will remain under active consideration for sixty (60) days from the date it is filed. It will then become inactive unless you notify this facility that you want to remain under consideration.
    The use of this application form does not indicate that there are any positions open and does not in anyway obligate you or the Louisville Care Community.

  2. Date of application(*)
    Please select a date when we should contact you.
  3. JOB INTEREST:
  4. Position Applied For(*)
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  5. Full Time or Part Time?(*)
    Please tell us how big is your company.
  6. Date Available For Work(*)
    Please select a date when we should contact you.
  7. What Hours Are You Available To Work?(*)
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  8. Louisville Care Community is an equal opportunity employer and hires qualified individuals without regard to race, color, sex, age, national origin, religion, disability, or status as a Vietnam era veteran, special disabled veteran, recently separated veteran, or veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized, or any other protected classes.

  9. PERSONAL:
  10. First Name(*)
    Please type your full name.
  11. Last Name(*)
    Please type your full name.
  12. Address(*)
    Please type your full name.
  13. City
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  14. State
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  15. Zip
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  16. How long have you been at this address?(*)
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  17. E-mail(*)
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  18. Telephone No(*)
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  19. Are you at least 18 years of age?(*)
    Please specify your position in the company
  1. EDUCATION:
  2. High School (Name, Location, Highest Grade)(*)
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  3. College or University (Name, Location, Major, Highest Grade or Degree Completed)
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  4. Trade or Vocational (Name, Location, Major, Highest Grade or Degree Completed)
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  5. Business or other (Name, Location, Major, Highest Grade or Degree Completed)
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  6. SPECIALIZED TRAINING:
  7. List all licenses, areas of certification or any other special training
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  8. LICENSE INFORMATION:

    Licenses and Certifications (licensed professionals, medication aides and nurse aides)

  9. License Type
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  10. Date Issued
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  11. License Number
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  12. State Issued
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  1. Have you ever been convicted of any crime, rather it be a felony or misdemeanor, other than a minor traffic violation?(*)
    Please specify your position in the company
  2. If yes, please list crime, date of conviction, county and state of conviction, and sentence or other disposition (A record of a conviction of a crime will not necessarily disqualify you from consideration for employment.):
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  3. Have you ever been convicted in a court of law of a crime involving abuse, neglect or mistreatment of an individual?(*)
    Please specify your position in the company
  4. Have you in the past 7 years worked for The Louisville Care Community?(*)
    Please specify your position in the company
  5. If yes, please indicate time period and position you worked at The Louisville Care Community:
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  1. PAST EMPLOYMENT:

    Please indicate a continued record of employment, beginning with your most recent position. Include what you have done for the last 5 years, or from the time you left school.

  2. If you are currently employed, may we contact your present employer?(*)
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  3. 1 - Employer’s Name (*)
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  4. Address(*)
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  5. Phone(*)
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  6. Job Title(*)
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  7. Job Duties(*)
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  8. Supervisor(*)
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  9. Rate of Pay(*)
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  10. From Mo/Yr To Mo/Yr(*)
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  11. Reason for Leaving(*)
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  12. ------------------------------
  13. 2 - Employer’s Name
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  14. Address
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  15. Phone
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  16. Job Title
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  17. Job Duties
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  18. Supervisor
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  19. Rate of Pay
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  20. From Mo/Yr To Mo/Yr
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  21. Reason for Leaving
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  22. ------------------------------
  23. 3 - Employer’s Name
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  24. Address
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  25. Phone
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  26. Job Title
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  27. Job Duties
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  28. Supervisor
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  29. Rate of Pay
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  30. From Mo/Yr To Mo/Yr
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  31. Reason for Leaving
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  32. ------------------------------
  33. 4 - Employer’s Name
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  34. Address
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  35. Phone
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  36. Job Title
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  37. Job Duties
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  38. Supervisor
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  39. Rate of Pay
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  40. From Mo/Yr To Mo/Yr
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  41. Reason for Leaving
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  42. ------------------------------
  43. 5 - Employer’s Name
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  44. Address
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  45. Phone
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  46. Job Title
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  47. Job Duties
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  48. Supervisor Name
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  49. Rate of Pay
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  50. From Mo/Yr To Mo/Yr
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  51. Reason for Leaving
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  1. REFERENCES:

    Please list the names of three persons not related to you and whom you have known at least one year.

  2. Reference 1 (Name, Address, Phone and/or Email)(*)
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  3. Reference 2 (Name, Address, Phone and/or Email)(*)
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  4. Reference 3 (Name, Address, Phone and/or Email)(*)
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  5. PLEASE READ THIS SECTION BEFORE SIGNING!

    FALSIFICATION OF RECORDS
    I completed this application and I certify that the information in this application is correct to the best of my knowledge. I understand that falsification of this application or omission of requested information in any detail is grounds for disqualification from further consideration or for dismissal from employment.

    EMPLOYMENT AT WILL
    I will follow the rules and regulations of the Louisville Care Community as communicated to me. I understand that in no event shall my hiring be considered as creating a contractual relationship between myself and the Louisville Care Community. Unless otherwise provided in writing, the employment relationship shall be defined as “employment at will,” and either party may dissolve the relationship without cause. I further understand that no employee or supervisor, except the Administrator or designee, has the authority to enter into any agreement or contract of employment for any specific terms of employment such as length of service, future salary increases or agreement contrary to this application. Furthermore, I understand that any such agreement entered into by the Administrator or designee will not be enforceable unless it is in writing.

    CONDITIONAL OFFER OF EMPLOYMENT
    If I receive a conditional offer of employment, I understand that I may be the subject of drug screening, criminal background study and/or physical screening and evaluation. I hereby consent to such screening and record checks.

    PROOF OF RIGHT TO WORK
    If I am offered a position with this center, I understand that as a condition of employment I will be required to prove identity and right to work as required by the Immigration Reform and Control Act of 1986.

    PARTICIPATION IN GOVERNMENT PROGRAMS
    I agree to inform my supervisor or Administrator if I become subject to exclusion from any Federal or State Health Care Program [as defined by 42 U.S.C. 1320a-7] as a vendor, provider or employee or contractor of a participating provider or if I become aware that I may be subject to such exclusion.

    RELEASE OF INFORMATION
    I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize the Louisville Care Community to (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references or any other persons who can verify information; and (3) discuss the results of any investigation with other employees of the Louisville Care Community involved in the hiring process. In addition, I give my consent for all contacted persons, including former employers, to provide information concerning this application, and I release each such person from liability for providing information to the Louisville Care Community.

    FAIR TREATMENT PROGRAM
    As a term and condition of my employment, and unless covered by an individual employment contract or a collective bargaining agreement with different dispute resolution provisions, I agree to waive my right to a jury trial in any action or proceeding related to my employment with the Louisville Care Community. I am doing so voluntarily and knowingly. I understand that I have the right to consult with counsel before signing this document. I agree that all claims and disputes relating to my employment with the Louisville Care Center shall be decided by a mediator or arbitrator selected in accordance with the rules and procedures established by the national Arbitration Forum.

    AMERICANS DISABILITIES ACT
    Federal law obligates us to provide a reasonable accommodation to the known disabilities of applicants and employees, unless to do so would pose an undue hardship. Please feel free to let us know if you need an accommodation to complete the application process or to perform any essential elements of the position sought.