the villages of wilkes

The Villages of WilkesPO Box 1247, North Wilkesboro, NC 28659Fax 336-667-5357

Employment Application Form Please Complete Pages 1-6

OFFICE USE ONLY:

Date received:Reviewd by:

Date

Name Last First Middle Maiden

Present Address Street City State Zip

How long at current address? Social Security Number

Phone Number

Are you under 18? Yes No If "YES", can you provide proof of your eligibility to work? No Yes

No YesAre you currently authorized to work in the United States? Proof of eligibility will be required if hired.

Position applied for (1)

And wage desired (2)(Be specific)

Days/hours available to work

No Preference

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How many hours can you work weekly?

Employment desired

FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME

When are you available to start work?

TYPE OF SCHOOL NAME OF SCHOOL LOCATION (Complete mailingaddress)

NUMBER OFYEARS

COMPLETED

MAJOR & DEGREE

High School

College

Bus. or Trade School

Professional School

Have you ever been convicted of a crime which is substantially related to the functions or qualifications of the job forwhich you are applying? (A conviction record will not necessarily disqualify you from employment.)

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/werecommitted, sentence(s) imposed and type(s) of rehabilitation:

No Yes

APPLICATION FOR EMPLOYMENT

PAGE 2

DO YOU HAVE A DRIVER'S LICENSE? Yes No

What is your means of transportation to work?

Driver's license number OperatorCommercial(CDL)

Chauffeur

Expiration date

Have you had any accidents during the past three years?

Have you had any moving violations during the past three years?

How many?

How many?

OFFICE POSITIONS ONLY

Typing

Personal Computer

WPM

10-key Word Processing

Other Skills

Yes No

Yes No

PC Mac

Yes No Yes No

WPM

Please list three references other than relatives:

Name

Phone Number

Name

Phone Number

Phone Number

Name

Please use this space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluatingyour qualifications for employment. You may include hobbies, volunteer experience and any other activities you believe relevant. Pleaseomit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability.


State of Issue


MILITARY

Have you ever been in the armed forces?

Are you now a member of the National Guard?

Yes No

Yes No

Specialty Date EnteredDischarge Date

Work Exerience Please list your work experience for the past seven years beginning with your most recent job held.If you were self-employed, give name of firm. Attach additional sheets if necessary.

Name of employer

Address

City, State, Zip Code

Phone Number

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of last supervisor

EmploymentDates From To

Your last job title

Name of employer

Address


Phone Number





Your last job title

Pay orsalary FinalStart

FinalStartPay orsalary



PAGE 4

Name of employer

Address


Phone Number





Your last job title

Name of employer

Address


Phone Number





Your last job title

May we contact your present employer? Yes No

Did you complete this application yourself? Yes No

If not, who did?

After reviewing the attached job description, please indicate if you are able to perform the essential functions of the job for which youhave applied.If you answered "No," please identify those job functions that you cannot perform. If a reasonable accomodation is required to enable youto perform the job properly and safely, please describe:

NoYes





PAGE 5

PLEASE READ CAREFULLY

APPLICATION FORM WAIVERPlease indicate that you have read and understood each sentence by signing your initials in the spaces provided below.

In exchange for the consideration of my job application by The Villages of Wilkes, hereinafter called “the Company,” I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the positionapplied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policystatements and the like as they may exist from time to time, or other Company practices shall serve to create an actual or impliedcontract of employment, _____ or to confer any right to remain an employee of the Company or otherwise to change in anyrespect the employment-at-will relationship between it and the undersigned, _____ and that relationship cannot be altered exceptby a written instrument signed by the Owner/Managing Member of the Company. _____ Both the undersigned and the Companymay end the employment relationship at any time, without specified notice or reason. _____ If employed, I understand theCompany may unilaterally change or revise their benefits, policies and procedures, and such changes may include reduction inbenefits. _____

I authorize investigation of all statements contained in this application. _____ I understand that the misrepresentation or omissionof facts called for is cause for dismissal at any time without any previous notice. _____ I hereby give the Company permission tocontact schools, all previous employers (unless otherwise indicated), references and others, and hereby release the Companyfrom any liability as a result of such contact. _____

I understand that, in connection with the routine processing of your employment application, the Company may request from aconsumer reporting agency an Investigative Consumer Report including information as to my credit records, character, generalreputation, personal characteristics and mode of living. _____ Upon written request from me, the Company will provide me withadditional information concerning the nature and scope of any such report requested by it, as required by the Fair CreditReporting Act. _____

I further understand that my employment with the Company shall be probationary for a period of ninety (90) days and further thatat any time during the probationary period of thereafter, my employment relationship with the Company is terminable at will forany reason by either party. _____

Signature of applicant: _________________________________________________ Date: _____________________________

The Villages of Wilkes is an equal employment opportunity employer. We adhere to a policy of making employment decisionswithout regard to race, gender, sexual orientation, religion, ethnic grouping, class or social condition. We assure you that youropportunity for employment with The Villages of Wilkes depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.



PAGE 6

The Villages of Wilkes, Skilled Nursing Facility, has a strong commitment to providing the highest level of care for all who residein our home. Providing innovative and progressive cultural changes along with dedicated and committed leadership, wechallenge ourselves to be forerunners in the world of long term care. We take pride in our facilities and work diligently to createan environment that is conducive to the personal growth of both staff and residents. In order to provide focus and direction forour goals and endeavors, I will agree to adhere to the following set of standards that exemplify the high level of commitmentnecessary to fulfill our common goals.

I, ______________________________, do hereby commit to the following as terms and conditions of my employment at theVillages of Wilkes:

I commit to excellence in care. I will not hesitate to answer the need for assistance, and will not ignore situations such as callbells, pleas for help or mechanical alarms that may be heard throughout the facility.

I commit to the financial success of the facility. I will respectfully utilize all property contained within the facility, and will attemptto preserve the property by not abusing or misplacing it. I will show good stewardship of the facility's funds by researching allnecessary purchases for the best price, completing a purchase order prior to a purchase and keeping proper inventory of all stockentrusted to my care.

I commit to the adherence to all policies and procedures. I will remain knowledgeable about all policies and procedures,researching new policies as they are added and choosing never to deviate from the guidelines set for me by the Administration.

I commit to all families, without prior judgment, who choose to bless us with the opportunity to care for their loved one. I willshow no bias towards residents or their families regardless of race, gender, sexual orientation, religion, ethnic grouping, class orsocial condition. I will strive to provide support, both emotionally and spiritually, and to remain a positive connection betweenthe facility and the families of those who reside in our home. I will respond to all requests in a timely manner, remembering tobe considerate and courteous.

I commit to all residents. I will strive each day to take the moments to touch the lives of those who reside in our home. I willuplift, encourage and hold with highest regard those with whom I come in contact on a daily basis.

I commit to all staff. I will provide positive encouragement and a high level of teamwork, and promote acceptance of all of myfellow employees. I will refrain from gossip, back-biting, malicious slander or any other form of negative communication thatmay result in negative feelings or dissatisfaction.

I commit to personal growth. I will strive to acquire the knowledge, information and education that prepares me to take thesteps towards completing my personal goals as well as the goals set by the Villages.

I commit to the responsibility and accountability that follow suit. I will assume responsibility for all areas of employment that aretouched by my presence within the facility. I will accept total responsibility for my own actions, which means that I will standsolely for all decisions that are made and be willing to suffer the negative consequences for those that fall below standard.

___________________________________________________________________________________Signature of Employee

___________________________________________________________________________________Date


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