Employment – Job Application | Rochester Manor + Villa

About Me

Name

First

Middle

Last

Address

Street Address

Address Line 2

City

State

ZIP Code

Phone

Alternate Phone

Email

Have you ever worked for this company before?

Yes
No

Social Security Number (SSEC #)

Position I Am Applying For*

Date available to begin work

Education

List

Name of School	City / State	Completed Yes / No	Degree

Please list High School first, then College, Vocational / Tech or Business School.

Professional Licenses and/or Certifications

List

Type	Organizations or State Issued	Date Issued	Number	Verified

Please list High School first, then College, Vocational / Tech or Business School.

Have you lived in the state of Pennsylvania for the last two years?

Yes
No

Are you 18 or older?

Yes
No

Are you 21 or older?

Yes
No

Have you ever been convicted of a felony?

Yes
No

If Yes, for what, when and where?

620.64(E)(II) I have no history of or conviction for violent crime and was never dismissed from employment due to abuse of clients or residents

True
False

Conviction of a criminal offense will not necessarily preclude your employment

Employment History

Current Employer

Employed by

From

To

Address

Street Address

Phone

Position

Starting Salary

Please enter a number greater than or equal to 0.

Ending Salary

Please enter a number greater than or equal to 0.

Supervisor's Name

First

Last

Reason for Leaving

1st Recent Employer

Employed by

From

To

Address

Street Address

Phone

Position

Starting Salary

Please enter a number greater than or equal to 0.

Ending Salary

Please enter a number greater than or equal to 0.

Supervisor's Name

First

Last

Reason for Leaving

2nd Recent Employer

Employed by

From

To

Address

Street Address

Phone

Position

Starting Salary

Please enter a number greater than or equal to 0.

Ending Salary

Please enter a number greater than or equal to 0.

Supervisor's Name

First

Last

Reason for Leaving

May we contact your present employer?

Yes
No

Were you in the armed forces?

Yes
No

Branch

Date of Duty: From

To

Rank at Discharge

If your former employment references, education, or military service are under another name, please indicate below

How did you hear about us?

Newspaper

Name

Current Employee

Name

Other

Explain

Personal References (Not Relatives)

Name	Phone	Years Acquainted

Will you accept employment of

Full Time
Part Time
PRN

Can you perform the essential functions of the job with or without an accommodation?

Type of Work Desired

First Choice	Shift	Second Choice	Shift	Third Choice	Shift

Rochester Manor And Villa Substance Abuse Policy

Rochester Manor and Villa is committed to maintain a safe workplace for employees, to promoting employee health, and to providing meaningful, effective and
efficient services for our residents. Our commitment requires that our workplace be free from the effects of alcohol, controlled substances and any
substances that might jeopardize resident safety, employee safety, or performance.

All applicants for employment may be tested randomly for the presence of controlled substances. An applicant whose test reveals the presence of any mind altering drug will not be hired.

No employee shall work or report to work under the influence of any substance that impairs his or her ability to work safely and productively. No employee
shall possess or use alcohol, illegal drugs or any substance that impairs the employee’s ability to work safely and productively on Rochester Manor and
Villa property during working hours, including lunch and rest periods, or while working for Rochester Manor and Villa though not on Rochester Manor and
Villa property. Property includes Rochester Manor and Villa vehicles and parking lots. Employees violating any of these prohibitions will be disciplined up
to and including termination.

If Rochester Manor and Villa has a reasonable basis to believe that an employee has violated this policy, it may ask the employee to submit to a random
alcohol and/or drug test. “Reasonable basis” includes, but it’s not limited to, smell of alcohol on breath, the deterioration of the employee’s conduct,
performance or attendance, or involvement in a work-related accident or injury in which the employee appears to be wholly or partially responsible. An
employee who refuses to submit to testing will be treated as if testing positive. Employees admitting to be under the influence of alcohol, or any
substance that impairs their ability to work safely and productively and who does not consent to testing will be treated as if testing positive and be
terminated.

Employees who drive vehicles will be subject to random testing if required by federal or state regulations.

Employees are responsible for seeking treatment before any substance abuse effects their workplace conduct, performance or attendance.

Acknowledgement of Rochester Manor And Villa Substance Abuse Policy*

I understand.

By checking, you acknowledge this policy. (required)

Disclosures, Acknowledgement and Signature

THIS INSTITUTION DOES NOT DISCRIMINATE IN HIRING OR ANY OTHER DECISION ON THE BASIS OF RACE, COLOR, SEX, CITIZENSHIP, NATIONAL ORIGIN, ANCESTRY, VIETNAM ERA VETERAN STATUS, OR ON THE BASIS OF AGE OR PHYSICAL OR MENTAL DISABILITY UN RELATED TO ABILITY TO PERFORM THE WORK REQUIRED. NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMANTION TO BE USED FOR SUCH DISCRIMINATION.

I VOLUNTARILY GIVE THIS INSTITUTION THE RIGHT TO MAKE A THOROUGH INVESTIGATION OF MY PAST EMPLOYMENT AND ACTIVITIES, AGREE TO COOPERATE IN SUCH INVESTIGATION AND RELEASE FROM ALL LIABILITY OR RESPONSIBILITY ALL PERSONS, COMPANIES OR CORPORATIONS SUPPLYING SUCH INFORMATION.

I UNDERSTAND THAT MY EMPLOYMENT IS AT WILL, AND THAT EITHER PARTY IS FREE TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME WITHOUT CAUSE. I ALSO UNDERSTAND THAT MY EMPLOYMENT MAY BE TERMINATED FOR ANY REASON MISSTATEMENT OR OMISSION OF FACT ON THIS APPLICATION FORM.

IF EMPLOYED, I WILL BE REQUIRED TO COMPLETE AN EMPLOYMENT VERIFICARION FOR (I-9), AND WITHIN THREE DAYS SHOW SATISFACTORY EVIDENCE OF IDENTITY AND ELIGIBLITY FOR EMPLOYMENT.

I ATTEST THE INFORMATION CONTAINED HERIN IS TRUE, CORRECT AND COMPLETE

Applicant Signature

Applicant's Signature (Print)

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