Position(s) Applying For: *

Rate of Pay Expected: *

Date Available: *

Would you work: *

Full Time

Part Time

PRN (as needed)

If part time/PRN, specify days/hours: *

Referral Source: *

Referred by current employee? *

Yes

No

Employee Name: *

PERSONAL INFORMATION

Last Name: *

First Name: *

Middle Name: *

Street Address: *

City: *

Zip: *

Phone Number: *

Email: *

Are you legally eligible for employment in the United States? *

If under age 18, state age: *

Have you ever applied to St. Monica’s before? *

Yes

No

Have you ever worked for St. Monica’s before? *

Yes

No

EDUCATION / LICENSES / CERTIFICATIONS

High School: *

Diploma/GED: *

Yes

No

Year: *

College/Technical School: *

Degree/Program: *

Other Education/Training: *

Licenses or Certifications, if applicable:

License/Certification Number(s):

Expiration Date(s):

EMPLOYMENT HISTORY — BEGIN WITH MOST RECENT

1. Employer:

From/To:

Phone:

Address:

Job Title:

Supervisor:

Salary/Rate:

Reason for Leaving:

May we contact this employer?

Yes

No

If no, explain: *

2. Employer:

From/To:

Phone:

Address:

Job Title:

Supervisor:

Salary/Rate:

Reason for Leaving:

May we contact this employer?

Yes

No

If no, explain: *

3. Employer:

From/To:

Phone:

Address:

Job Title:

Supervisor:

Salary/Rate:

Reason for Leaving:

May we contact this employer?

Yes

No

If no, explain: *

BUSINESS & PROFESSIONAL REFERENCES

Please list two business/professional references, preferably past supervisors or instructors.

Name: *

Phone: *

Relationship: *

Name: *

Phone: *

Relationship: *

REQUIRED DISCLOSURE OF PRIOR NAMES / ALIASES

Have you ever used any other name, including maiden name, former married name, legal name change, nickname, alias, or any other name associated with employment, criminal, licensing, certification, education, or government records? *

Yes

No

CRIMINAL HISTORY / PENDING CHARGES DISCLOSURE

Have you ever been convicted of a crime, entered a plea of guilty or no contest, or been found guilty of any offense other than minor traffic violations? *

Yes

No

If yes, explain: 1) nature of offense, 2) date of conviction, 3) state/county, and 4) name used at the time of offense, if different from current legal name. *

Do you currently have any pending criminal charges against you? *

Yes

No

If yes, describe: 1) nature of charges, 2) date issued, 3) county/state, and 4) current status. *

Are there any criminal, employment, licensing, certification, or government records under another name that have not been disclosed above? *

Yes

No

If yes, explain: *

Note: A conviction is not an automatic bar to employment. Employment decisions will be made in accordance with applicable law, caregiver background check requirements, and position-related resident safety considerations.

APPLICANT CERTIFICATION AND BACKGROUND CHECK AUTHORIZATION *

I certify that all information provided in this application is true, complete, and accurate.

I understand that I am required to disclose ALL names I have used, including maiden names, married names, former names, aliases, and legal name changes.

I understand that false, incomplete, or omitted information, including failure to disclose prior names, criminal history, pending charges, employment history, licensing/certification status, or other required information, may result in withdrawal of a job offer or termination of employment.

I authorize St. Monica’s Senior Living, Inc. to obtain criminal history and caregiver background check information as permitted or required by law.

I understand that I have the right to obtain a copy of any criminal history record, challenge the accuracy/completeness of the record, and obtain a determination regarding the challenge before a final employment/association decision is made.

I understand that employment is contingent upon successful completion and review of all required caregiver background check documentation.

I understand that I have an ongoing obligation to immediately report any change in background status, including arrests, charges, convictions, governmental findings, caregiver misconduct findings, placement on an exclusion/misconduct registry, or legal name changes.

Applicant Signature: *

Date: *

Employment Form

Training That Moves You Forward

PERSONAL INFORMATION

EDUCATION / LICENSES / CERTIFICATIONS

EMPLOYMENT HISTORY — BEGIN WITH MOST RECENT

BUSINESS & PROFESSIONAL REFERENCES

REQUIRED DISCLOSURE OF PRIOR NAMES / ALIASES

CRIMINAL HISTORY / PENDING CHARGES DISCLOSURE