GENERAL INFORMATION

Full Name *

Address

Street Address *

City *

State *

Country *

Postal code *

How long at address listed above?

Home Telephone: *

Applying for what position? *

If yes, explain: *

If yes, list address: *

For this type of employment, State Law requires a criminal record check as a condition of employment pursuant to KRS216.793(1).

Are there any felony charges pending against you? *

Yes

No

If yes to either question, provide details including nature of the crime, dates and location: *

In order to verify your records, please list any other name(s) (i.e. maiden) by which you may have been known: *

EDUCATION & TRAINING INFORMATION

I. High School:

I.1 School/Location *

II. College(s):

III. Graduate School:

IV. Business/Vocation:

V. Apprentice training or other course:

LICENSES, CERTIFICATES, OR PROFESSIONAL MEMBERSHIPS: *

References

(Give the names of three person to be used as work related references)

Reference #1

I. Address *

Reference #2

II. Occupation *

Reference #3

III. Occupation *

Employment History

(Please begin with your most recent employer.)

I.3 Starting Pay Rate $ *

I.5 Describe work performed: *

I.9 Supervisor *

I.11 Reason for leaving *

II.3 Starting Pay Rate $ *

II.5 Described work performed: *

II.9 Supervisor *

II.11 Reason for leaving *

III.3 Starting Pay Rate $ *

III.5 Describe work performed *

III. 9 Supervisor *

III.11 Reason for leaving *

Military Information

Specialty: *

Certification & Agreement

I authorize the release to Arcadia Communities (and/or any of its licensed agents) of information held by any parties regarding my previous employment, criminal history record and/or record of convictions in state and local files for violations of any federal, state, local statutes or ordinances, military records, medical records, credit history, driving record and scholastic records and hereby release said persons, schools, companies, government agencies, court and law enforcement authorities from any damage whatsoever for releasing this information. I certify that all the information I have provided on this application is true and accurate. I understand that misstatements, omissions, or false or misleading statements which I have provided on this application, on my resumé and/or in interview(s) shall constitute grounds for refusal to hire or immediate termination from employment. I understand that the terms and conditions of employment may be changed at any time without notice by the company. In consideration of employment with Arcadia Communities agree to comply with all the policies, procedures and requirements of Arcadia Communities. I understand this application and/or any Arcadia Communities manual, handbook or other written document describing such items do not constitute a written contract at this time or in the future. I understand my employment would be at-will and that my relationship, oral or written, can only accomplished by a written document signed by Arcadia Communities Chairman/President/CEO or Board of Directors.

I have read and understand the above.

Applicant's Signature *

Clear

Date *