Employment Application

Caring for seniors is a calling. If this describes you, we are looking to employ you. You provide compassionate, quality care for the elderly in your community, and you support their families as they make decisions about next steps for their loved ones. To accomplish that goal, we need a team of people who share your vision and passion. Living Well Assisted Living is a beautiful facility set in a wooded community setting that will truly make you feel at home. Consider sharing your skills with us.

Whether you work in an assisted living community, a skilled nursing facility, or a home care agency, we depend on our people to carry out our mission every day. But finding those people isn’t always easy. See what our community thinks about us.

Last Name *

First Name *

MI

Place of Birth *

Are you 18 years of age or older? *

Yes

No

Address *

Street Address

*

City

*

State

*

Postal Code

Telephone #1 *

Telephone #2 *

Position Applying for *

Special Training and/or Certification *

Are you either a US Citizen or an alien authorized to work in the US? *

Yes

No

Have you been convicted of a felony or misdemeanor in the last five years? *

Yes

No

If YES, explain: *

Date of Last TB test or X-Ray (if known) *

(Please list last five years of work history. Caregivers must be 18 years of age and have a minimum of 3 months health related experience. Managers must be 21 years of age and have 12 months health related experience.)
The ADHS rules require that each employee have two professional reference checks.

Employer #1 *

Employer Name
Position Held
Date Employed From
To
Employer Address
Employer Phone

Employer #2

Employer Name
Position Held
Date Employed From
To
Employer Address
Employer Phone

Employer #3

Employer Name
Position Held
Date Employed From
To
Employer Address
Employer Phone

(You must have two verifiable character references who are Unrelated to you)

Reference #1 *

Reference Name
Address
Phone

Reference #2 *

Reference Name
Address
Phone

All employees of an Assisted Living Facility must submit to a background check through the State Police. You must be willing to submit to this background check to assure you have not been convicted of any crime of abuse of a vulnerable adult, sexual abuse, incest, first or second degree murder, kidnapping, arson, sexual assault, sexual exploitation of a minor, felony offenses involving distribution of marijuana or narcotic drugs, theft, robbery, a dangerous crime against children, child abuse, sexual conduct with a minor, molestation of a child, manslaughter, aggravated assault, domestic violence, fraud and fraudulent schemes, assault within the last five years or possession of a dangerous narcotic within the last five years.

Living Well Assisted Living is an Equal Opportunity Employer, committed to diversity in the workplace. All qualified applicants will receive consideration for employment without regard to gender, race, color, national origin or ancestry, religion, age, physical or mental disability, medical condition, sexual orientation, gender identity or expression, military or protected veteran status, or marital status.

To the best of my knowledge all information provided on this application is true. I understand that providing false information on this application is grounds for termination.