Employment Application

RidgeStone Assisted Living
Application for Employment

We are an EQUAL OPPORTUNITY EMPLOYER. We do not discriminate in hiring or employment on the basis of race, color, religion, gender, national origin, age, disability or on any other basis prohibited by federal, state or local laws. No question on this form in intended to secure information to be used for any such discrimination. A criminal background check is required by the State of Wisconsin, the results of which may prohibit employment under State of Wisconsin HFS 83 and/or 89. By State regulation, all employees are required to be at least 18 years of age.

All fields with an asterisk (*) are required to be completed.

Name *
Address *
City, State ZIP *
How long have you been at this address? *
Previous address including street address, city and state:
Day time phone number: *
Position applied for: *
Number of hours you wish to work: * (1 required)
Full time Part time
Have you ever been previously employed with us? *
Yes No
If yes, please give dates:
Are you legally authorized to work in the United States? (Proof of your identity and work authorization will be required upon employment.) *
Yes No
RidgeStone Assisted Living provides care for our residents 24 hours a day, seven days a week. All staff members are required to work weekends and holidays on a rotation basis. You may also be asked to fill in for absent co-workers on an on-call basis.
Are you available for work under these conditions? *
Yes No
May we contact your current employer? *
Yes No
Employment History
Start with you present or last job and list all of your employment regardless of length of time for each.
Employer:
Dates employed (start and end/present):
Full address including street, city, state & zip code
Supervisor name:
Phone number:
Position held:
Starting wage:
Ending wage:
Reason for leaving:
Employer 2
Dates employed (start and end/present):
Full address including street, city, state & zip code
Supervisor name:
Phone number:
Position held:
Starting wage:
Ending wage:
Reason for leaving:
Employer 3
Dates employed (start and end/present):
Full address including street, city, state & zip code:
Supervisor name:
Phone number:
Position held:
Starting wage:
Ending wage:
Reason for leaving:
Education
Level of education completed: *
Name and address of school: *
Do you have certification (HFS 83/89 approval number course) in any of the following:
Fire Safety First Aid Training Standard Precautions Medications Dietary Needs Client Group Specific Needs Assess/ISP Challenging Behaviors Block 1: Residents Rights
Are you currently certified as a CNA? *
Yes No
Are there any restrictions that would prohibit you from performing this job? *
Yes No
Have you ever been convicted of a crime? *
Yes No
If yes, explain (Convictions will not automatically disqualify job applicants. The nature of the crime and date of conviction will be considered):
Describe any education, training, special experiences, volunteer activities which you feel may qualify you for the position for which you ar applying:
References
List the name, business name, address, email address and telephone number of three business references that are familiar with your job-related abilities and skills:
Reference 1 *
Reference 2 *
Reference 3 *
Additional reference
A cover letter and/or resume may be uploaded as part of your application.

(allowed file types: doc, docx, pdf, txt, xls, xlsx)
Applicant's Certification, Authorization and Release Statement

I certify that the information provided by me in this application and given during the interview proxess, whether orally or in writing, is true and complete to the best of my knowledge and belief. I understand and agree that any omission or misrepresenation of fact as stated or implied, may result in the denial of employment or in termination if I am hired, and that the Company shall not be held liable in any respect if my employment is terminated for that reason.

I understand that all information furnished in this application may be verified by the Company or its authorized representative and I authorize the Company to do so. i waive any right I may have to notice from any individuals and organizations named or referred to in this application prior to the release of any employment information to the Company. I hereby authorize all individuals and organizations named or referred to in this application, and any law enforcement organization, to give the Company all information relative to such verification and herby release and hold harmless such individuals, organizations and the Company from any and all liability for any claim or damage resulting there from.

I understand that if I am hihred, I am required to abide by all the rules, policies and procedures of the Company. I also understand that the Company's rules, policies and procedures are subject to modification without notice to me.

I also understand that the Company is not obligated to provide emloyment and that I am not obligated to accept employment. Nothing in this application or in any prior oral or written staments is intended to create a contract of employment. If I am hired by the Company, I understand that my employment will at all times be at-will, and for no definite period, and that either the Company or I may end the employment relationship at any time without notice or cause. I understand that only the Company President has the authority to enter into any agreement contrary to the foregoing. Any such agreement with the President must be in writing and signed by the President of the Company.

I understand that this application form will be considered current for only 60 days, and that I will need to complete a new application form if I wish to be considered for employment beyond that period.

I have read and understood the above.
Type your name as a signature of acceptance *
Date signature added: *
Enter Your Email Address: *

RidgeStone Assisted Living Application for Employment

Employment History

Education

References

Applicant's Certification, Authorization and Release Statement

I understand that if I am hihred, I am required to abide by all the rules, policies and procedures of the Company. I also understand that the Company's rules, policies and procedures are subject to modification without notice to me.

I understand that this application form will be considered current for only 60 days, and that I will need to complete a new application form if I wish to be considered for employment beyond that period.

I have read and understood the above.

RidgeStone Assisted Living
Application for Employment