<p> Employment Application</p><p>Name (first, middle, and last) </p><p>Mailing Address </p><p>Phone ( ) E-mail Address </p><p>Position(s) applied for: Application Date: </p><p>Preferred location: Apartments Long-Term Care Either location </p><p>Pay Rate Desired: </p><p>Have you applied here before? No Yes If yes, list title and date: </p><p>Are you employed now? No Yes On what date would you be available for work? </p><p>Are you available to work? Full time Part time PRN Days/Times available? </p><p>Are you legally eligible for employment in the U.S.? No Yes</p><p>Are you over the age of 18? No Yes</p><p>Do you have any relatives employed by McCrite Plaza? No Yes</p><p>If yes, provide name and relationship: Have you been convicted or pled guilty to a felony or misdemeanor other than moving traffic violations?</p><p>No Yes</p><p>If yes, please complete the following (a conviction record will not necessarily be a bar to employment):</p><p>Conviction: Location Date Result or outcome: EDUCATION</p><p>High School Trade Schools College/University School Name Diploma / GED / Degree received Certificate Received Describe Course of Study</p><p>1 Employment Application</p><p>EMPLOYMENT EXPERIENCE</p><p>List your past four employers including military and voluntary service assignments. Start with your present or last job. Attach an additional sheet if necessary.</p><p>Employer Telephone Address: Supervisor: Job Title and Duties: Dates Employed: From to Salary: Starting to Reason for leaving: Work Performed: May we contact: Yes No </p><p>Employer Telephone Address: Supervisor: Job Title and Duties: Dates Employed: From to Salary: Starting to Reason for leaving: Work Performed: May we contact: Yes No </p><p>Employer Telephone Address: Supervisor: Job Title and Duties: Dates Employed: From to Salary: Starting to Reason for leaving: Work Performed: May we contact: Yes No </p><p>2 Employment Application</p><p>Employer Telephone Address: Supervisor: Job Title and Duties: Dates Employed: From to Salary: Starting to Reason for leaving: Work Performed: May we contact: Yes No </p><p>Please summarize your job-related skills or specialized training: </p><p>Are you licensed as an: RN LPN LPN IV Cert. CMA CMT CNA</p><p>What state(s) are you licensed in? </p><p>PROFESSIONAL REFERENCES</p><p>Give the name and telephone number of three (3) business/work references who are not related to you and have knowledge of your professional abilities. </p><p>List the following for each reference:  Name  Occupation/Job Title  Company Name  Phone Number</p><p>Reference: </p><p>Reference: </p><p>Reference: </p><p>3 Employment Application</p><p>ACKNOWLEDGEMENT</p><p>I understand that McCrite Plaza is making no employment offer at this time. *I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination if employed. </p><p>I authorize McCrite Plaza to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, driving record, and other relevant information, if job-related. I give my full consent for all contacted persons including former employers to provide the information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to McCrite Plaza. I acknowledge that a facsimile of this form is as valid as the original.</p><p>A drug test and/or physical examination may be required. I understand that any offer of employment may be withdrawn if I test positive for drugs and/or if a condition is discovered for which no reasonable accommodation can be made.</p><p>I understand that if I am hired, my employment at McCrite Plaza is “at-will” and may be terminated by myself or by the McCrite Plaza at any time, with or without cause or notice. I understand that no representative, other than the Owner/President has the authority to make any assurance to the contrary.</p><p>I have read and understand the above information.</p><p>Name (Printed) Signature</p><p>Date</p><p>4 QUESTIONNAIRE</p><p>NAME: </p><p>1. Why do you want to work for this company? </p><p>2. What personal performance standards do you set for yourself? </p><p>3. When we check your references, what will they say related to your strengths? </p><p>4. What will they say related to a weakness or area for improvement? </p><p>5. Describe a difficult circumstance and how you handled it. </p><p>6. What was your greatest accomplishment this year? </p><p>7. Describe your vision of the “ideal” supervisor. </p><p>8. What approach would you take to introduce a new idea or way of doing things to the boss or team? </p><p>9. Other comments: THE FOLLOWING ARE COMPANY POLICIES THAT WE WANT ALL APPLICANTS TO KNOW ABOUT. THESE POLICIES APPLY ONLY IF AN APPLICANT IS OFFERED A POSITION.</p><p>DRESS ATTIRE A specific uniform dress is required for the following types of roles:</p><p> Certified Nurse’s Aides and Home Health Aides – Navy scrubs with company logo and non-slip shoes. Jewelry must be appropriate and not pose a safety issue (i.e. something that can tear the skin). Piercings in the nose, eyebrow, tongue, or any other body part that is visible are not allowed; </p><p> Food Service/Restaurant - Gray polo shirt for the Topeka location and black polo shirt for the Briarcliff location with company logo, black slacks, black non-slip shoes, a black apron, hairnets, no jewelry of any kind (includes piercings in the nose, eyebrow, tongue, or any other body part), no painted finger nails, false nails, and men cannot have facial hair or must provide and wear beard guards;</p><p> Housekeeping - Purple scrubs for the Topeka location and teal scrubs for the Briarcliff location with company logo and non-slip shoes. Jewelry must be appropriate and not pose a safety issue (i.e. something that can tear the skin). Piercings in the nose, eyebrow, tongue, or any other body part that is visible are not allowed;;</p><p>TOBACCO-FREE WORKPLACE McCrite Plaza maintains a tobacco-free work and living environment. Smoking and/or the use of tobacco is not permitted anywhere on McCrite Plaza property at any time. The definition of McCrite Plaza property for the purpose of this policy includes all land, buildings, structures, parking lots, and means of transportation owned by or leased to McCrite Plaza. This means that the only time someone can use tobacco or smoke is on the 30 minute meal break and that individual must be clocked out and off company property.</p><p>CELL PHONES AND TEXT MESSAGING Personal cell phones are only to be used (i.e. returning phone calls, text messages, instant messaging, tweets, and other electronic communication methods) at times of “rest: such as meal breaks and rest periods. </p><p>Acknowledgement of receipt: I have read this information and I understand that it was given as a part of the application packet as a reference only.</p><p>Name </p><p>Date AUTHORIZATION TO RELEASE INFORMATION</p><p>I authorize McCrite Plaza, and its representatives, to contact any company, institution, law enforcement agency, state agency, bureau or individual it deems appropriate to investigate my employment history, job performance, background, qualifications, driving record, and other relevant information, if job related. I grant my full consent for all contacted persons including former employers to provide information relevant to this application. I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to McCrite Plaza.</p><p>Name: Signature: ______</p><p>Date: </p><p>Maiden Name and/or other names known by: </p><p>Gender: Birth date: </p><p>Social Security Number: </p><p>Driver’s License Number*: State driver’s license issued from*: </p><p>If applying for a position at McCrite Plaza Topeka, have you lived outside of the State of Kansas? If yes, please list your previous address: </p><p>McCrite Plaza currently verifies information on or with: . Prior employment . References . State and county criminal records; *Please note information gathered from a criminal background check will be compared against information provided on the application. Any misrepresentation or omission of any fact on the application is grounds for disqualification from further consideration for employment or for termination if employed.</p><p>According to the Fair Credit Reporting Act, applicants are entitled to know if insurance or employment is denied because of information obtained by the prospective employer from a consumer-reporting agency.</p><p>*Positions in the following departments may be required to drive a vehicle on behalf of McCrite Plaza which requires a current driver’s license:  Maintenance  Nursing  Activities  Dietary  Marketing</p>