Employment - Chardonnay Assisted Living

Personal Information

Name(Required)

First Last

Phone Number(Required)

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

Resume

Max. file size: 1 GB.

Additional Information

Do not include any information that could be considered sensitive (SSN, Driver’s License #, etc)

Are you currently employed?(Required)

Date available to start?(Required)

Have you applied with our company before?(Required)

Additional Information(Required)

Please let us know when you applied and any additional information you would like us to consider

Have you worked in assisted living before?(Required)

Are you willing to work overtime?(Required)

Have you been convicted of a felony in the past 7 years?(Required)

Please explain(Required)

Are you willing to consent to a criminal background check?(Required)

Are you willing to consent to random drug testing?(Required)

Do you have a current First Aid certification?(Required)

Expiration Date(Required)

Do you have a current CPR certification?(Required)

Expiration Date(Required)

Do you have a current CNA license?(Required)

Expiration Date(Required)

Do you have a medication assistance certification in Idaho?(Required)

Do you have any other current nursing/medical certification or licensing? If so, please list them below:

How many hours a week are you available to work?(Required)

What shifts are you able to work?(Required)

You may select more than one

Days

Evenings

Nights

Please list the following: School Name, Location, Dates Attended, Graduation Date/ Degree(Required)

Please describe all special qualifications and skills pertaining to Caregiving, Elderly Care, Assisted Living. Why would these skills make you an ideal candidate for the job?(Required)

Employment History

Please list the most recent first.

Company Name

Location

Supervisor Name

Phone Number

May we contact your supervisor?(Required)

Yes

Dates of Employment

Position

Rate of Pay

Reason for Leaving:

Company Name

Location

Supervisor Name

Phone Number

May we contact your supervisor?(Required)

Yes

Dates of Employment

Position

Rate of Pay

Reason for Leaving:

Company Name

Location

Supervisor Name

Phone Number

May we contact your supervisor?(Required)

Yes

Dates of Employment

Position

Rate of Pay

Reason for Leaving:

Personal References

Name

First Last

Phone

Years Known

Relationship

Name

First Last

Phone

Years Known

Relationship

Name

First Last

Phone

Years Known

Relationship

Acknowledgement

I hereby authorize Chardonnay Assisted Living (the company) to contact any company, person or educational institution I listed as a reference on my employment application. I hereby allow any company, person, or educational institution I listed as a reference on my employment application to disclose any information they may have regarding my qualifications for employment, including but not limited to employment dates, descriptions of jobs performed, salary and wage rates and personal attributes. I agree to release and discharge Chardonnay Assisted Living and Chardonnay Assisted Living’s successors, employees, officers, and directors as well as any company, person, or educational institution I have listed as a reference for all claims, liabilities, and causes of action, known or unknown, fixed or contingent, for providing or receiving any information regarding my qualifications for employment. This release includes but is not limited to claims of defamation, libel, slander, negligence, or interference with contract or profession.

Name(Required)

First Last

Date(Required)

I have read the paragraph above and agree to the terms and conditions of the application(Required)

Confirmation

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