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Employment Application Haga click acá para ir a la versión en Español.
Indicates a Required Field
Create a Username & Password
Username:
TIP: Using your email address as your username will make it easier to remember.
Password:
Re-enter Password:
 
Referral Source
How did you hear about us?
If you were referred to us by an employee, please indicate who:
 
Contact Information
First Name: 
Middle Initial:
Last Name:
Suffix (if any):
E-Mail Address:   
Day Phone:    Evening Phone:
Address: 
City:   
State/Province:             
Zip/Postal Code:
Country: (2-letter official abbreviation)
Example: United States = "US", Canada = "CA"
 
Contact Comment:
  
Example: "Best time to call...." or "Contact only via email"
 
Descriptive Phrase:
Use 3-5 words that best describes your professional experience (i.e. "Seasoned RN" or "Experienced Physical Therapist").
Social Security Number (SSN):    
If you are under 18, please state your age:
Are you legally authorized to work in the US for any employer?
Yes No
Have you lived in the state of Pennsylvania for the last 2 years?  Yes No
If no, Please provide your former address below.
Address:
City:
State/Province:
Zip Code:
Maryland Applicants Only: Have you lived in any other state of the United States in the past 7 years? Yes No
If your answer is yes, specify the city:
 
Employment Information
Which facility are you interested in working at:
What are your areas of expertise? 
(Select all that apply)
   
What kind of job are you looking for? 
(Check all that apply)
Desired Hourly Range:
 
Personal Experience
Level of Education:    
 
High School: City, State: Degree: Did you graduate?
Si No
 
University: City, State: Degree: Did you graduate?
Si No
 
Other: City, State: Degree: Did you graduate?
Si No
 
Have you previously applied to/worked for Country Meadows?
Yes No
If "Yes" Please Explain:
Have you previously worked at a retirement home or nursing center? Yes No
If "Yes" Please Explain:
 
Do you have any convictions for criminal offenses?
Yes No
If "Yes" Please Explain:
 
Are you able to perform the essential functions of the position(s) to which you are applying with or without reasonable accommodations? Yes No
  
Work Experience
Were you ever discharged by any company? Yes No
 
Present Employer:
Address:
Supervisor's Phone:
Dates Worked: From:   To:
Wage: Starting: $ Leaving: $
Job Title:
Description of Duties:
Reason for Leaving:
May we contact this employer? Yes No
 
Previous Employer:
Address:
Supervisor's Phone:
Dates Worked: From:   To:
Wage: Starting: $ Leaving: $
Job Title:
Description of Duties:
Reason for Leaving:
May we contact this employer? Yes No
  
Military Experience
Have you ever served in the Armed Forces of the United States? Yes No
If yes, which branch?
List duties including special training:
Dates of Service: From:   To:
 
Your resume or a brief description of your past responsibilities, special skills and certifications.
Enter text resume only.
You can cut and paste your resume from another source, or simply type in the space below. The resume field is text only. For best results, do not use symbols, bullets, bolding etc. We consider the skills and experience described vs. the resume format.

Reference 1 		 
   
Reference Name:
Business Name:
Business Address:
Business Phone:
Years Known:

Reference 2		  
   
Reference Name:
Business Name:
Business Address:
Business Phone:
Years Known:

Reference 3		  
   
Reference Name:
Business Name:
Business Address:
Business Phone:
Years Known:


STATEMENT 

I certify that the information given in this application is true and complete to the best of my knowledge. I understand that misrepresentation or omission of information provided in my application or interviews may result in discharge, no matter when discovered. I authorize investigation of all statements contained in this application and investigation into my background and references. I release this organization and any other individual or entity from any and all liability, whatsoever, associated with obtaining or releasing information about me.

I understand and agree that my employment relationship with Country Meadows and the Ecumenical Community may be terminated either by me or by Country Meadows/Ecumenical Community at any time and for any reason, without prior notice to the other party,and that no written or oral policy of Country Meadows/Ecumenical Community concerning continued employment is now or will ever be intended to constitute an express or implied contract. Wages, benefits and other terms and condition of employment may be changed from time to time at the discretion of Country Meadows/Ecumenical Community.

It is further understood that there are not now and will not in the future be any express or implied contractual terms of continued employment between Country Meadows/Ecumenical Community and me, unless such terms are set forth in writing, signed both by me and by either the President or Vice President of Country Meadows/Ecumenical Community.

I certify that I do not have any history of or conviction for violent crime, moral offenses or of abusing persons, except as noted on this application. I further certify that I was never dismissed from employment due to abuse of clients or residents.

Date:
Signature:
 
Type text from Security Image below:


By clicking submit, I agree to the preceding statements.


Home Office - 830 Cherry Drive, Hershey, PA 17033 - 800-322-3441

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