The Broadway | Elder Living and Rehabilitation

Personal lnformation

Full Name: *

(First and Last)

Email: *

Current Address: *

Current Address:

(City)

(State/Province)

(Zip Code)

(Country)

Telephone: *

How did you hear about us?

Position Desired

Position applying for: *

What days of the week are you available to work?

Do you have the legal right to work in the U.S.? *

Yes

No

Are you under 18 years of age? *

Yes

No

Have you ever been convicted of a crime? *

Yes

No

If yes, please explain the offense, date and place. *

*Conviction of a criminal offense will not necessarily prevent your employment.

Have you ever worked for any facility affiliated with the Elder Outreach company, including Louisiana facilities such as the Southwind, Encore, Pelican Pointe, Eastridge, The Broadway, The Vermilion or The Acadian? *

Yes

No

Where?

When?

Department?

Supervisor?

Reason for leaving?

Please list any friends or relatives currently working at this facility.

Can you perform the functions of the job for which you are applying with or without reasonable accommodations? *

Yes

No

Please describe any reasonable accommodations you may need.

Education

Please select the highest level achieved: *

If other, please specify.

Professional License or Certificate

Employment Record

Please list the most recent seven years of employment history.

Employer Name: *

Do you currently work here?

Yes

No

Start Date:

End Date:

Job Title: *

Supervisor: *

Work / Duties Performed? *

Hourly Rate / Salary? *

Reason for leaving? *

Can we contact this employer?

Yes

No

Employer Name: *

Do you currently work here?

Yes

No

Start Date:

End Date:

Job Title: *

Supervisor: *

Work / Duties Performed? *

Hourly Rate / Salary? *

Reason for leaving? *

Can we contact this employer?

Yes

No

If you have additional employment information for the last 7 years, please add a new record/s with the "Add" button below.

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References

Please provide three (3) work-related references not related to you. If work-related references are not available, teachers, clergy, or other personal references may also be submitted.

Reference 1 Name: *

Relationship: *

Years Known: *

Reference Company Name (if applicable):

Reference Email: *

Reference Phone #: *

Reference Fax #: *

Reference 2 Name: *

Relationship: *

Years Known: *

Reference Company Name (if applicable):

Reference Email: *

Reference Phone #: *

Reference Fax #: *

Reference 3 Name: *

Relationship: *

Years Known: *

Reference Company Name (if applicable):

Reference Email:

Reference Phone #: *

Reference Fax #: *

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Employment Understanding and Acknowledgement

Employment by this company will be on an at-will basis and have a three (3) month probationary period. If employed by Elder Outreach, I agree to abide by its rules and regulations. I understand that this company will check the references provided in this application, including former employers, supervisors and schools. I give authorization to these individuals, companies, and schools to furnish information to this company. I release from all liability or responsibility this company, all persons, companies or corporations releasing or using this information.

I understand that I will be required to submit other background-related information so that various background checks can be conducted. I may also be required at any time to submit to employment physical examinations, drug tests, health screens as per company policy. I give authorization to the company to have access to this information.

I understand that I must produce a driver’s license, social security card or other documents proving my identity and right to work in the United States.

I certify that all information disclosed on this application is true and accurate. I understand that my employment will include a three (3) month probationary period and is at will. 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 misstatement or omission of fact appearing on this application.

We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status.

Do you understand and agree? *

Yes, I understand.

Electronic Signature *

Enter Full Name.

Date of Application: *

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Job Application

We invite you to apply for The Broadway by completing an employment application.

Application for Employment

Personal lnformation

Position Desired

Education

Professional License or Certificate

Employment Record

References

Employment Understanding and Acknowledgement

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