Text Size A+ A A- HomeEmployment OpportunitiesApplication 2 Application 2 Personal InformationName First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code Email Address Cell #Where did you learn of this opening?Other Phone #Employment InformationPosition(s) Applying ForDate Available Salary DesiredHours Desired Full-time Part-time Per Diem/Occasional Other If other, please specifyShift Availability Day Evening Night Weekends Only Other If other, please specifyHave you ever been dismissed from employment due to abuse of clients or residents?*YesNoIf yes, please explain:Have you ever been convicted of any misdemeanor involving theft, any felony, or any crime involving abuse or fraud?*YesNoIf yes, please explain:Education InformationHigh SchoolSchool NameCourse of Study# of YearsDid you graduate?CollegeSchool NameCourse of Study# of YearsDid you graduate?Trade, Business, or Correspondence SchoolSchool NameCourse of Study# of YearsDid you graduate?Employment ExperienceStart with your most recent jobDates EmployedName of EmployerLocationJob TitleReason for Leaving Describe any specialized training, apprenticeship, skills and extra-curricular activities. Summarize special job-related skills and qualifications acquired from employment or other experienceReferencesGive the names of three persons not related to you whom you have known at least one year.NameEmail AddressPhone Number Applicant's StatementThe facts set forth in my application for employment are true and complete. I understand that false statements on this application may be considered cause for rejection of this application or for termination of employment. I hereby authorize Landis Homes to investigate all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Landis Homes and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise is binding upon Landis Homes. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that Landis Homes retains a similar right. If offered employment at Landis Homes, I consent to taking a pre-employment physical examination, drug screen, and tuberculosis skin test or x-ray as required by the PA Department of Health, and authorize Landis Homes to complete a Criminal Background Check in regard to the Older Adults Protective Services Act. I certify that I was never dismissed from employment due to abuse of clients or residents. I certify that I have no history or conviction of violent crime. If you cannot certify the above items, please explain whyFull Name*Date* PhoneThis field is for validation purposes and should be left unchanged.