Employment

This application is a private document and will be held in a confidential manner. Information contained in this application must be true and accurate.

Personal Information

If hired, you will need to supply us with copies of your High School Diploma / GED, Driver’s License & Social Security Card. Further, in the event we offer employment, please be aware that the employee is responsible for paying for their CPR & First Aid recertification. Also, there is a $10.00 charge for a Criminal Background Check, and also $52.00 Occupational Privilege Tax.

Step 1 of 9

Personal Information

If hired, you will need to supply us with copies of your High School Diploma / GED, Driver’s License & Social Security Card. Further, in the event we offer employment, please be aware that the employee is responsible for paying for their CPR & First Aid recertification. Also, there is a $10.00 charge for a Criminal Background Check, and also $52.00 Occupational Privilege Tax.
Name*
First Last
Email*
Home Phone*
Cell Phone*
Address
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Social Security Number

Have you lived outside of Pennsylvania anytime within the last 2 years?*
- Yes
- No
Are you a citizen of the United States?*
If No, have you received employment authorization from the United States Immigration & Naturalization Service to work in the United States?*
Have you ever been employed by Alexandria Manor before?*
If yes, State date & location:
Area Of Position Desired*
Ideal Shift Choice*
Type of Employment Desired*
Pay Rate Requested
Location Desired*

Have you ever been convicted of a crime other than a minor traffic offense?*
If Yes, explain (Conviction of a crime is not an automatic bar to employment; all circumstances will be considered):*
Have you ever been convicted of Physical or Emotional Abuse?*
Do you have any physical limitations that would interfere with, or restrict your ability to perform the duties of the position(s) applied for?*
If Yes, please describe:
Have you ever been dismissed from employment due to abuse of clients or residents?*

Education
High School: Name & Location of School*
High School: Highest Grade Completed*
High School: Degree*
College: Name & Location of School*
College: Course Studied*
College: Degree*
Graduate Work: Name & Location of School*
Graduate Work: Course Studied*
Graduate Work: Degree*
Other Schooling: Please describe any other training, courses of study, or skills acquired:

Previous Employment Information

Appropriate documentation will be requested upon offer of employment
Employer 1: Company Name
Employer 1: Dates Employed Through
Employer 1: Job Title
Employer 1: Supervisor
Employer 1: Phone Number
Employer 1: Starting and Final Rate / Salery
Employer 1: Address
Employer 1: Describe Job Duties
Employer 1: Reason For Leaving
Employer 2: Company Name
Employer 2: Dates Employed Through
Employer 2: Job Title
Employer 2: Supervisor
Employer 2: Phone Number
Employer 2: Starting and Final Rate / Salary
Employer 2: Address
Employer 2: Describe Job Duties
Employer 2: Reason For Leaving
Employer 3: Company Name
Employer 3: Dates Employed Through
Employer 3: Job Title
Employer 3: Supervisor
Employer 3: Phone Number
Employer 3: Starting and Final Rate / Salary
Employer 3: Address
Employer 3: Describe Job Duties
Employer 3: Reason For Leaving

References

Provide three (3) Business References from previous jobs (for example: former Supervisor) who are not related to you. If you haven't worked before, give three (3) other references
Reference 1: Name
Reference 1: Phone
Reference 1: Address
Reference 2: Name
Reference 2: Phone
Reference 2: Address
Reference 3: Name
Reference 3: Phone
Reference 3: Address
Provide any additional information that would assist is in making our decision about your Application
(example: applicant for a clerical position should state typing speed & office equipment used)

Employee Information On Dismissals & Crime Convictions
Have you ever been dismissed from employment due to abuse of clients or residents*
If the answer is YES, please explain in detail the circumstances which led up to your dismissal(s).*
If this happened more than one time, please explain below each & every dismissal.
Do you have a history of, or have you ever been convicted of a violent crime?*
If the answer is YES, please explain in detail the circumstances which led up to your dismissal(s).
If this happened more than one time, please explain below each & every dismissal.
Please Verify - Prohibited Offenses*
- I certify that I have not been convicted of any of the prohibited offenses.
Click here to view the PDF of Prohibited Offenses. I understand that I am hired provisionally pending required background checks.

Training

Please select "Yes" for all the skills you have been trained in below.
Personal Care (ie: Bathing, Showering, Shampooing)*
Blood Pressures, temperatures, respirations, pulse*
Do you know how to do an Accu-check for Blood Sugar*
Do you know how to give Insulin Injections*
Are you certified in First Aid*
Are you certified in CPR*
Have you been trained in giving Medications*
Do you have basic Medical Knowledge*
Do you know how to use basic office equipment (ie: copier, phone, etc.)*
Have you ever dealt with an emergency situation*

I hereby certify that this application was completed by me and that all answers and information in it are true and complete to the best of my knowledge. I understand that false or misleading information given in this application and my interview(s) will void this application or subject me to discharge at any time, if I am employed.

I expressly acknowledge and understand that in the absence of a written contract to the contrary, my status, if I am hired, will be that of an employee at will, having no contractual right, expressed or implied, to remain in the Company’s employ. In this connection, I expressly acknowledge further that neither anything said to me during the Company’s application and/or interview process or during employment nor any provision in the Company’s employee handbook or personnel manual constitutes the terms of implied employment agreement. In consideration of any employment offered, I specifically agree that my employment may be terminated with or without cause or notice at any time, at the option of either the Company or myself. I understand that no unauthorized representative may enter into any agreement for employment or make any agreement contrary to the foregoing.

I expressly agree that my prior employer(s) and current employer may be contacted for the purpose of investigating my background, and I understand that information regarding my prior and current employment(s) may be used by the Company in considering this application. I also hereby permit my present and prior employer(s) to disclose to the Company information from my personal file(s) in their possession or subject to their control. In this regard, I expressly release the Company from any and all liability of whatever kind and nature which, at any time, may result from obtaining and making an employment decision based upon the requested information.

PLEASE do not call us to inquire about your application status. We will call you with any questions or to set up an interview.

Thank you for your time & interest in Alexandria Manor.

Alexandria Manor is an equal opportunity employer and employs individuals with requisite training, capability and experience regardless of race, religion, gender, national origin, sexual orientation or handicap, with reasonable accommodation.
Verify that all above information is accurate*
- I agree

Employment

Personal Information

Step 1 of 9

Personal Information

Education

Previous Employment Information

References

Employee Information On Dismissals & Crime Convictions

Training

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