MERIT HOUSE Employment Application Personal Information Date: Name: Social Security Number: (Last) (First) (Middle) Address: Phone: Alternate Phone: City: State: Zip: Position Desired Position Applied For: □ Full Time Date Available for Work: □ Part Time □ Temporary Shift Preference: □ Day □ Evening □ Night Have you ever applied to this company? Have you ever worked for this company? □ Yes □ No If yes when? □ No If yes when? □ Yes Do you have any relatives who work for this company? □ Yes □ Contingent □ Other □ Weekend □ Any □ No If yes, please identify: Have you ever been convicted or plead guilty to a crime (felony or misdemeanor) other than a minor traffic violation? If yes, explain: □ Yes □ No How did you hear about us? □ Newspaper □ Employee Referral □ School Recruiting □ Job Fair □ Community Agency □ Walk-In □ Nursing Assistant Program □ Open House □ Other: _ Work Authorization Are you legally authorized to work in the USA? □ Yes □ No To comply with the Immigration Reform and Control Act, if you are hired, you will be required to provide documents to establish your identity and your authorization to work in the USA Such documents will be required upon your first day of work -1- Record of Education Name and Address of School(s): Dates Attended From To Mo./Yr Mo./Yr Graduated Yes No Type of Degree/ Diploma Received Or Expected Field of Study High School (Last Attended) College/ University Graduate School Other (Business, Trade, etc.) Please list any professional affiliations or accreditations that have a direct bearing upon your qualifications for the job for which you are applying Include all licenses and certifications Have you ever had your professional license or certification suspended, revoked or restricted? If yes, please explain: □ Yes □ No Do you have any special skills or abilities related to the job for which you are applying? -2- Work Experience Employer Name: (Most recent experience first) Position: Employer Address: Reason for leaving: From Month Year Phone: Supervisor: Employer Name Position: Employer Address: To Month Supervisor: Employer Name: Position: Employer Address: To Year Phone: Month Supervisor: Employer Name: Position: Employer Address: Phone: Year Month □ Yes □ No If no, please give reason: Eligible for rehire? Year □ Yes □ No If no, please give reason: Reason for leaving: From Month Eligible for rehire? To Year Phone: □ Yes □ No If no, please give reason: Reason for leaving: From Month Year Reason for leaving: From Month Eligible for rehire? To Year Month Eligible for rehire? Year □ Yes □ No If no, please give reason: Supervisor: May we contact CURRENT employer listed above? □ Yes □ No References (Please not list any person related to you) Reference Name Address Phone -3- Certification of Accuracy & Consent PLEASE READ CAREFULLY AND SIGN BELOW I hereby certify that all of the information in this application is complete and accurate to the best of my knowledge and belief I understand and agree that any omissions or false or inaccurate statements in my application or interview may be justification for refusal to hire or termination of employment I hereby authorize the Company and/or its duly authorized agents to investigate all references, to contact all prior employers and to secure additional information about me concerning my qualifications for the position applied for I hereby release from liability the Company and/or its representatives for seeing such information I hereby authorize all prior employers, schools, any law enforcement agencies, investigative companies and any other persons, companies or governmental agencies to give the Company any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, concerning my qualifications for the position applied for I release all persons or entities from all liability for any damage or injury tat may result from furnishing information to the Company I also release the Company and all of its employees from all liability for any damage or injury that may result from reliance on the information furnished I understand and agree that nothing contained in this application or in the hiring process is intended to create an employment contract If I am offered and accept employment, I agree to abide by the Company’s Policies and Procedures, Employee Handbook and any governmental regulations I understand and agree that my employment is “at will” and therefore my employment can terminate, with or without cause, at any time at my option or the option of the Company This “at will” employment relationship may not be modified by any oral or implied agreement I understand and agree that I must meet all the physical standards established by the Company to perform the essential functions of any job for which I am offered employment I understand that if offered employment I will be required as a condition of employment to take physical examinations by a qualified health care professional I also understand that during employment I might from time to time be subjected to physical examinations and/or physical ability tests to demonstrate that I can perform the essential functions of my job I understand and agree that the company may require that I submit to drug and/or alcohol testing I understand and agree that all applicants will be required to undergo a post-offer, pre-employment drug test conducted by any contractor the Company designates Any offer of employment depends upon satisfactory completion of this screening, and the determination by the Company and the examining physician that the person is capable of performing the responsibilities of the position that has been offered I understand and agree that I may be required t submit to drug and/or alcohol testing during my employment The Company reserves the right to conduct searches on company property, vehicles and/or equipment at any time I further understand that if I refuse to submit to a company search I may be terminated I understand and agree that this application will remain active for 90 days If I still want to be considered for a position with the company after this application expires, it is my responsibility to complete a new application _ Signature _ Date -4-