Date:

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

Legal Name: *

Format: Last First Middle

Street Address: *

City: *

Zip: *

Phone Number: *

Email: *

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

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 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

PERSONAL INFORMATION

EDUCATION / LICENSES / CERTIFICATIONS

EMPLOYMENT HISTORY — BEGIN WITH MOST RECENT

BUSINESS & PROFESSIONAL REFERENCES

REQUIRED DISCLOSURE OF PRIOR NAMES / ALIASES