Employee Application

Fields marked with a * are required.

Personal Data:
* First Name:
* Last Name:
* Middle Name:
* Current Address:
* City:
* State:
* Zip:
* How long at current address?
* Telephone:
*Social Security Number:
* Former Address:
* City:
* State:
* Zip:
* Position applying for:
Salary requirements:
* Date available:
* Have you previously worked for Glenwood?: When?
Position held:
Do you have relatives employed at Glenwood ? Name(s):
 
Were you referred to Glenwood Healthcare? By Whom?
 
* If hired, can you verify that you are authorized to be employed in the United States? * Are you under 18 years of age? * List position you are applying for:
EDUCATION/TRAINING:
* Last grade completed:
* Are you currently attending school?:
If yes, estimated graduation date:
Month: Year:
COLLEGE INFORMATION
Undergraduate College/ University Attended:
Undergraduate Major Field:
Degree Received:
Graduate College/University Attended:
Graduate Major Field:
Degree Received:
List special skills
in training:
Academic honors or extra
curricular activities:
If presently enrolled, indicate where:

Field of study:
HIGH SCHOOL INFORMATION
Name of School:
Location:
Major Courses Taken:
Degree Received:
   
APPRENTICE BUSINESS, TECHNICAL OR VOCATIONAL SCHOOL
Name of School:
Location:
Major Field:
Diploma/Certificate Received:
   
FURTHER STUDY
Describe any definite plans for further study:
PREVIOUS EMPLOYMENT:
List most recent employer first. Include breaks in employment or periods of unemployment.
* Company Name:
* Employed From:
* To:
* Job Title:
* Starting Salary:
* Final Salary:
* Number and Street:
* City:
* State:
* Zip:
* Phone:
* Supervisor:
* Reason for leaving:
* Company Name:
* Employed From:
* To:
* Job Title:
* Starting Salary:
* Final Salary:
* Number and Street:
* City:
* State:
* Zip:
* Phone:
* Supervisor:
* Reason for leaving:
* Company Name:
* Employed From:
* To:
* Job Title:
* Starting Salary:
* Final Salary:
* Number and Street:
* City:
* State:
* Zip:
* Phone:
* Supervisor:
* Reason for leaving:
* Have you ever been discharged or asked to resign from any position?:
If yes please explain:
Unemployment Record: List all intervals of unemployment, if any during the last 10 years.
From – Month/Year: To – Month/Year: Brief Statement covering this period, if applicable.
MILITARY
Have you ever served in the
United States Military, Reserves,
or National Guard ?
Branch of Service:
Highest Rank:
Indicate any skills or training acquired during military service you
feel might be of interest or value to Glenwood Healthcare :
PERSONAL HISTORY
* Have you ever been convicted of a crime other than a minor traffic violation?

(This information will not necessarily bar an applicant from employment)
If yes, please explain fully including the date, place, nature of the
crime, and the date of conviction and completion of any sentence:
REFERENCES :
Give name, address, and telephone number of three references who are not related to you and are not previous employers.
* Name:
* Address:
* City:
* State:
* Zip Code:
* Phone Number:
* Name:
* Address:
* City:
* State:
* Zip Code:
* Phone Number:
* Name:
* Address:
* City:
* State:
* Zip Code:
* Phone Number:
RELEASE, PRIVACY STATEMENT, AND AGREEMENT TO ARBITRATE ALL CLAIMS:

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SUBMITTING AND COMPLETING THE APPLICATION.

I understand that Glenwood Healthcare (the “Company”) requires certain information about me to evaluate my qualifications for employment and to conduct its business if I become an employee. Therefore, I authorize Glenwood Healthcare to investigate my past employment, criminal record, credit, educational credentials, and other employment related activities. I agree to cooperate in such investigations and release all parties from all liability or responsibility with respect to the information supplied. I also agree to submit to any drug or alcohol testing which is required to qualify for employment for the Company.

I understand that this application is not an offer of employment and that by accepting my completed application, the Company does not guarantee that I will be offered a job. I also understand that if I am offered a job, the Company reserves the right to make such changes in terms and conditions of my employment as the Company determines to be necessary or appropriate.

I understand that an employment with Glenwood Healthcare would be an employment at will, meaning my employment would not be for any fixed period of time and that, if employed, I may resign at any time for any reason with or without notice and the Company has the same rights with regard to terminating my employment. I further acknowledge my understanding that statements which may be contained in policies, handbooks, and other the Company materials do not create any guarantee of employment nor contractual rights, express or implied, and I agree that I will not rely upon them as such. I also understand and agree that such policies may be changed at any time, with
or without notice. I further acknowledge that no supervisor, manager, executive or any employee or agent of the Company has the authority to alter any of the above, and that any promises to the contrary will only be relied upon by me if they are in writing and signed by the President of the Company and myself.

I certify that all the information I am supplying on this application is true and complete in all respects and that I am submitting this information and any other information during the application process so the Company can rely on this information in making employment decisions. I understand that, if I am employed, any false answers or statements made by me on this application or any supplement thereto or in connection with the above-mentioned investigations, regardless of when discovered by the Company, will be grounds for immediate disqualification or discharge. I understand also that I am required to abide by all rules and regulations of the Company.

I further understand that any offer of employment may be contingent upon successfully completing a medical evaluation indicating that I am able to perform the essential functions of the job, with or without reasonable accommodations.

In consideration for the Company’s agreeing to accept my application for consideration, I acknowledge and agree that any controversy or claim that I may have as an applicant shall be submitted, unless barred by the National Labor Relations Act. To binding arbitration before a single arbitrator with the arbitration to be conducted pursuant to the provisions of the Commercial Arbitration Rules of American Arbitration Association then in effect. I agree that (i) my application for employment; (ii) my employment, If I am subsequently hired by Glenwood Healthcare; and (iii) the business of the Company affects or has direct impact upon “interstate commerce,” as defined in the Federal Arbitration Act, 9 U.S.C. §1, and that this provision is enforceable there under. All costs and expenses of arbitration, including compensation expenses of the arbitrator, shall be borne by the Company

I acknowledge that I have read, understand, and agree to abide by the terms of the above RELEASE, PRIVACY STATEMENT, AND AGREEMENT TO ARBITRATE ALL CLAIMS.
* Applicant:
* Email:
* Date: