Personal Information

Last Name   First Name   Middle Initial   Email

Present Address

Apt. City   State   Zip

How Long have you lived at present address?

Previous Address

Apt. City State Zip

How Long have you lived at Previous address?

Phone      Are you at least 18 years old? YesNo

Are you legally eligible for employment in the USA? YesNo

Do you have reliable transportation to work? YesNo

Position(s) you are applying for:   Rate of pay per hour $

Work Status Needed: Part TimeFull TimePRN

Please List preferred shift: First Choice:   Second Choice:

Were you previously employed by Rolling Green Village? YesNo   If yes, what year?

Do you have any friends or relatives working for Rolling Green Village? YesNo

How did you learn of this position?

Have you ever been bonded: YesNo   If yes, for what job(s) ?

Have you ever been convicted of a felony, misdemeanor or offense other than minor traffic violations? YesNo   If yes, describe in full:

On what date would you be available to begin work?

Why would you like to work at Rolling Green Village:

Education Record

High School	Name:	state:	Did you Graduate?
GED	Where:	state:
College	Name:	state:	How Long?
	Course of study:		Degree:
	Name:	state:	How Long?
	Course of study:		Degree:
Other	Name:	state:	How Long?
	Course of study:		Degree / Diploma:
Certifications of Licensures (Please be specific)
List any other experiences, skills, hobbies or qualifications that may benefit our Occupation:

Military Service Record

Were you in the US Armed Forces?	YesNo
If you have served in the military, list Branch:
Dates of Duty	From: To:
Rank at Discharge:
List any duties in the Service that are relevant for the position being applied for:

Employment Record

Company / Location / Supervisor	Phone	Dates of Employment
Your Job	Salary	Reason for Leaving
Company / Location / Supervisor	Phone	Dates of Employment
Your Job	Salary	Reason for Leaving
Company / Location / Supervisor	Phone	Dates of Employment
Your Job	Salary	Reason for Leaving
Company / Location / Supervisor	Phone	Dates of Employment
Your Job	Salary	Reason for Leaving
May we contact your former employers?
If not, which ones?

Professional References

NO RELATIVES PLEASE

Name / Address / Phone #
Occupation:
Name / Address / Phone #
Occupation:
Name / Address / Phone #
Occupation:
Name / Address / Phone #
Occupation:

Please read below

I understand that nothing contained in this application or in the interview process is intended to create an employment contract between me and Rolling Green Village (RGV). If I am employed by RGV, I will be an employee-at-will. This means that both RGV and I have the right to terminate my employment at any time, for any reason, with or without cause. I also acknowledge that upon receiving an offer of employment, I may be required to successfully complete a pre-employment physical, PPD skin test, and/or drug test.

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice. In making this application for employment I authorize you to make an investigative consumer report whereby information is obtained through personal interviews with my neighbors, friends or others with whom I am acquainted. This inquiry, if made, may include information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of any such investigative report that is made.

VOLUNTARY AFFIRMATIVE ACTION INFORMATION

Completion of information below is voluntary.

In an effort to comply with requirements regarding Affirmative Action record keeping, please complete this applicant data survey. Your cooperation is appreciated.

The survey is not part of your official application for employment. It is considered confidential information that will not be used in any hiring decision,

Name:
List the title of the position(s) applied for:
Gender	MaleFemale
Please identify yourself within one of the following Ethnic Groups: Hispanic or Latino* Not Hispanic or Latino *Includes persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish origin or culture regardless of race.
If you are Not Hispanic or Latino, please identify yourself within one of the following Racial Groups WhiteBlack or African AmericanNative Hawaiian or Other Pacific Islander AsianAmerican Indian or Alaska NativeTwo or more races *Includes persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish origin or culture regardless of race.
How did you learn about the job(s)? NewspaperGovernment AgencyEmployment Agency Job ServiceFriendRelative EmployeeInternet PostingCompany Website Other: Person Referring you (if applicable): *Includes persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish origin or culture regardless of race.

SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS AND INDIVIDUALS WITH PHYSICAL OR MENTAL DISABILITIES:

Our voluntary Affirmative Action program is subject to the Vietnam Era Veterans Readjustment Act of 1974 and Rehabilitation Act of 1973. Therefore, we are required to take affirmative action to employ and advance in employment qualified veterans and veterans of the Vietnam Era, and qualified disabled individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.

IF YOU SO W1SH TO BE IDENTIFIED, PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:

Vietnam Era VeteranDisabled VeteranIndividual with a disability

An Equal Opportunity Employer

Rolling Green Village is committed to equal opportunity for all. This policy governs our business activities in a manner which provides equal opportunity and treatment for all employees without regard to race, sex, color, religion, national origin, age, disability or veteran status.