LOUISVILLE CARE COMMUNITY - APPLICATION FOR EMPLOYMENT

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.

Date of application
Please select a date when we should contact you.

JOB INTEREST:
Position Applied For
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Full Time or Part Time?
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Date Available For Work
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What Shifts Are You Available To Work?

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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.

PERSONAL:
Last Name
Please type your full name.

First Name
Please type your full name.

Middle Name
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Address
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City
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State
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Zip
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Telephone No
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E-mail
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Preferred Contact Method

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Are you at least 18 years of age?
Please specify your position in the company

How long have you been at this address?
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EDUCATION:
High School (Name, Location, Highest Grade)
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College or University (Name, Location, Major, Highest Grade or Degree Completed)
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Trade or Vocational (Name, Location, Major, Highest Grade or Degree Completed)
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Business or other (Name, Location, Major, Highest Grade or Degree Completed)
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SPECIALIZED TRAINING:
List all licenses, areas of certification or any other special training
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LICENSE / CERTIFICATION INFORMATION:

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

License Type
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Date Issued
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License Number
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State Issued
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Certification Type
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Date Issued
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Training Completed at
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State Issued
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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

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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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

Have you in the past 7 years worked for The Louisville Care Community?
Please specify your position in the company

If yes, please indicate time period and position you worked at The Louisville Care Community:
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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.

If you are currently employed, may we contact your present employer?
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1 - Employer’s Name
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Address
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Phone
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Job Title
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Job Duties
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Supervisor
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Rate of Pay
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From Mo/Yr To Mo/Yr
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Reason for Leaving
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2 - Employer’s Name
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Address
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Phone
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Job Title
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Job Duties
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Supervisor
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Rate of Pay
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From Mo/Yr To Mo/Yr
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Reason for Leaving
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3 - Employer’s Name
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Address
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Phone
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Job Title
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Job Duties
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Supervisor
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Rate of Pay
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From Mo/Yr To Mo/Yr
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Reason for Leaving
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4 - Employer’s Name
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Address
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Phone
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Job Title
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Job Duties
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Supervisor
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Rate of Pay
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From Mo/Yr To Mo/Yr
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Reason for Leaving
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5 - Employer’s Name
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Address
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Phone
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Job Title
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Job Duties
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Supervisor Name
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Rate of Pay
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From Mo/Yr To Mo/Yr
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Reason for Leaving
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REFERENCES:

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

Reference 1 (Name, Address, Phone and/or Email)
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Reference 2 (Name, Address, Phone and/or Email)
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Reference 3 (Name, Address, Phone and/or Email)
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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.


AFFIRMATIVE ACTION SURVEY FOR APPLICANTS

Louisville Care Community is a government contractor, subject to governmental regulations and affirmative action responsibilities. Applicants are considered for positions for which they apply and employees are treated during employment without regard to race; color; sex; national origin; age; disability; or status as Vietnam-era veteran, special disabled veteran and 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 class.

To assist with required recordkeeping, reporting and other legal requirements please fill out this confidential survey. Providing this information is voluntary and refusal to provide this information will in no way affect your status as an applicant. This survey will be kept in a separate confidential file and will be used only for governmental reporting purposes.

Date Applied
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Job Applied For
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Last Name
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First Name
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Social Security # (SSN)
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Gender

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Ethnicity

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Veteran – Check If Any of The Following Apply to You
Are you a veteran?
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Served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

Are you a Vietnam-Era Veteran?
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Served more than 180 days in active military, naval or air service any part of which was from August 5, 1964, through May 7, 1975, and discharge or release from active duty was because of a service connected disability or for other than dishonorable discharge, or if any part of such active duty occurred in the Republic of Vietnam between February 28, 1961, and May 8, 1975.

If employee referred you, who referred you?
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