APPLICATION FOR EMPLOYMENT

We are an equal opportunity employer. We offer employment to applicants on the basis of the individual's qualifications for a position. The selection is made in compliance with all applicable law and regulation without regard to an individual's race, color, religion, ancestry, national origin, age, status as a veteran, sexual orientation, handicap or disability which does not interfere with performance of the essential functions of the job, with or without reasonable accommodation. Please review all data on this application before submitting it for consideration.

Please share some basic personal information: Today’s Date:

Last Name:
First Name: Middle Initial:
Street Address: Apt.:
City, State, Zip:
Home Telephone:
Alternate Number:


 

 

 

 

Have you been a resident at your current address for a period of at least two years? Yes No

If No, please list your previous address

Street Address: Apt.:
City, State, Zip:

Are you legally eligible for employment in the United States? Yes No

Note: If “Yes,” verification will be required.

Are you over the age of eighteen? Yes No

If “No,” employment requires that you are of minimum legal age.

Have you been convicted of a crime in the past seven years, excluding traffic violations and summary offenses, which has not been annulled or expunged or sealed by a court? Yes No

If yes, describe in full:

Conviction of a crime will not be an absolute bar to employment, except as provided by the Pennsylvania Older Adult Protective Services Act.

List the position for which you are applying. Do NOT list “Any,” be specific:

:Were you previously employed by us? Yes No

If yes, when?

If you are offered employment and accept, on what date will you be available for work?

Please list all Days & Hours available to work:

Please tell us about your education and training by completing the following:

School Name and Address of School Course of Study Check
Last Year
Completed		 Did
You
Graduate		 List
Diploma
or Degree
Elementary 5 6
7 8		 Yes
No
High School 1 2
3 4		 Yes
No
College 1 2
3 4		 Yes
No
Other
(Specify)		 1 2
3 4		 Yes
No

Are there any other experiences, skills, or qualifications which will be of special benefit in the job for which you are applying? Please do not list any data that Federal and/or State law prohibits us obtaining prior to employment, such as age, race, etc.

LIST BELOW PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT:

Name and Address of Company From To Weekly
Starting
Salary		 Weekly
Last
Salary		 Reason
For
Leaving		 Name of
Supervisor
Month Month
  Year Year        
Telephone: Describe the work you did:
Name and Address of Company From To Weekly
Starting
Salary		 Weekly
Last
Salary		 Reason
For
Leaving		 Name of
Supervisor
Month Month
  Year Year        
Telephone: Describe the work you did:
Name and Address of Company From To Weekly
Starting
Salary		 Weekly
Last
Salary		 Reason
For
Leaving		 Name of
Supervisor
Month Month
  Year Year        
Telephone: Describe the work you did:

PLEASE LIST EMPLOYMENT REFERENCES WE MAY CONTACT. PLEASE DO NOT REPEAT FORMER SUPERVISORS LISTED ABOVE AS WE WILL REFERENCE CHECK ALL LISTED PREVIOUS EMPLOYMENT. PLEASE DO NOT LIST RELATIVES.

Name and Occupation Address Phone Number

 

By my signature below I acknowledge the following and confirm my authorization for the noted actions by Deer Meadows Retirement Community:

The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I further understand that this application is not, and is not intended to be, a contract of employment, nor does this application obligate Deer Meadows Retirement Community in any way if Deer Meadows decides to employ me. I understand and agree that my employment is at-will and can be terminated by either party with or without notice, at any time, for any reason or no reason. No one other than a member of the current Executive Management Team has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, and then only in a writing signed by the Executive Director of Deer Meadows Retirement Community.

Deer Meadows Retirement Community is an equal opportunity employer in compliance with the Civil Rights Act of 1964 and the Americans with Disabilities Act. This organization prohibits discrimination in employment practices because of race, color, religion, sex, age, national origin, or handicap/disability. No question on this application is asked for the purpose of limiting or excluding any applicant's consideration for employment because of his/her race, color, religion, sex, age, sexual orientation, national origin, or handicap/disability. Further, the Age Discrimination Employment Act of 1967, as amended, prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age or older and Deer Meadows is compliant with that Act.

Federal Law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization at time of hire as defined by current regulation. Failure to submit such proof within the required time shall result in immediate employment termination.

I agree to undergo a pre-employment drug test screening and understand that employment is contingent upon satisfactory results of the drug test stating that I show no evidence of taking illegal drugs. When employed, I agree to abide by and comply with all policies and procedures of Deer Meadows Retirement Community and understand that hours of work and other working conditions are subject to change at the discretion of Deer Meadows Retirement Community.

I understand that nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between Deer Meadows Retirement Community and me 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 Deer Meadows Retirement Community unless made in writing. If an employment relationship is established, I understand and agree that Deer Meadows Retirement Community has the right to terminate my employment at any time, for any reason, with or without notice. I realize that I will remain at all times an at-will employee and that I retain a similar right to leave the employment of Deer Meadows Retirement Community at any time.

I certify that I have read and understand all statements in this application and that my answers and statements are true and complete. I hereby give my permission for Deer Meadows Retirement Community to check my background with Federal, State, or Local police agencies, and to contact the employers listed on this application for employment. I realize that for falsification or omission of any information on this application, the receipt of a poor reference, a job-related felony or misdemeanor conviction record, disqualifying State or Federal criminal record information, or the failure to successfully complete a physical examination may be the cause for rejection or dismissal from employment.

I hereby authorize my former employers to furnish their records of my service and my reason for leaving their employ, together with all information they have concerning me whether on record or not. I also release any individual, partnership, or corporation which formerly employed me, its officers, agents, and employees, from any liability for any damage whatsoever for issuing such information and release Deer Meadows Retirement Community from any liability for the use of all such information.

I hereby authorize any schools, colleges, or institutions of education I have attended to furnish their records or transcripts of my grades, honors, achievements, class standing, teacher's evaluations and test results, together with all information they may have concerning me whether on record or not. I also release any individual, school, or institution, its officers, agent and employees, from any liability for any damages whatsoever for issuing such information.

I understand that for everyone's safety, there are video surveillance cameras placed throughout the facility. These video cameras record activity on a 24-hour/7 day a week basis. The cameras are monitored intermittently. Cameras are not placed in resident rooms or private care related areas. Cameras are located at entrance doors, healthcare corridors, both lobby areas, dining areas in Walton Center, cafeteria, Eden Area, Wellness Center, and main kitchen area as well as the parking areas. Recorded criminal acts may be prosecuted. If I become employed by DMRC I am aware that I will be working with the presence of the cameras mentioned above.

And finally, I authorize the investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

Print Applicant Name:

Signature and Date:

Thank you for your interest in employment with Deer Meadows!

Thank you, too, for your time in completing this application for employment, and providing the needed data.

Please also complete the following sheets that will allow processing of your application. The supplemental data requested is separate from this application and will NOT be submitted to the hiring manager. The Deer Meadows Human Resources Department retains the supplemental data in compliance with applicable law and regulation. These data are used appropriately in the employment process to confirm your eligibility for employment.

If you have any questions about this application, the attachments, the employment process or Deer Meadows Retirement Community, please contact the Human Resources Department at 215.624.7575.

For use only by the Deer Meadows Human Resources Department

Arrange Interview 0 Yes 0 No

Remarks _______________________________________________________________________________________________

___________________________________________________ ______________________________________
INTERVIEWER DATE

Employed 0 Yes 0 No Date of Employment ____________________________________
Hourly Rate/
Job Title: _____________________ Salary ____________ Department ___________________________

By ______________________________________________________________________________________
Print HR Rep Name and Title Date

NOTES

Deer Meadows Retirement Community
8301 Roosevelt Boulevard, Philadelphia, PA 19152 Phone: 215.624.7575

Date: _____________________
Confidential FAX to Human Resources
TO: ____________________________________________ 215.624.2750

____________________________________________

____________________________________________
Dear Employer:
The applicant named below has applied for a position of
with us and states that he/she previously worked for you. We would appreciate if you would supply the information requested below, and return this letter to us. A stamped, self-addressed envelope is enclosed for your use and convenience. If you reply via FAX, please mail this original form to follow the FAX.

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby give my permission for Deer Meadows Retirement Community to check my background with Federal, State, or Local police agencies, and to contact the employers listed on this application for employment. I realize that for falsification or omission of any information on this application, the receipt of a poor reference, a job-related felony or misdemeanor conviction record, disqualifying State or Federal criminal record information, or the failure to successfully complete a physical examination may be the cause for rejection or dismissal from employment.

I hereby authorize my former employers to furnish their records of my service and my reason for leaving their employ, together with all information they have concerning me whether on record or not. I also release any individual, partnership, or corporation which formerly employed me, its officers, agents, and employees, from any liability for any damage whatsoever for issuing such information and release Deer Meadows Retirement Community from any liability for the use of all such information.

I hereby authorize any schools, colleges, or institutions of education I have attended to furnish their records or transcripts of my grades, honors, achievements, class standing, teacher's evaluations and test results, together with all information they may have concerning me whether on record or not. I also release any individual, school, or institution, its officers, agent and employees, from any liability for any damages whatsoever for issuing such information.

And finally, I authorize a photocopy of this form to be valid as if the original, and I authorize the investigation of all statements contained in my application for employment as may be necessary in arriving at an employment decision.

Print Applicant Name:

Signature and Date:


TO BE COMPLETED BY FORMER EMPLOYER Thank you for your complete reply!

Applicant's Name
Employed From To Last Position
Reason for Leaving: Was Work Satisfactory?
Was Attendance Record Acceptable? Would you rehire? Comments:
Signature and Date:
Print Your Name and Title:
Deer Meadows Retirement Community
8301 Roosevelt Boulevard, Philadelphia, PA 19152 Phone: 215.624.7575

Statement of Abuse-Free History and Pre-employment Inquiry Release

Note: This form is separate from the employment application and is NOT submitted to the hiring manager. The Deer Meadows Human Resources Department retains this form and these data in compliance with applicable law and regulation. These data are used appropriately in the employment process to confirm your eligibility for employment.

Please read and review the following before completing the requested data below.

By my signature below I affirm and attest to these facts:

In connection with my application for employment with Deer Meadows, I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that Deer Meadows will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, workman's compensation and other experiences as well as claims involving me in the files of insurance companies.
I also specifically affirm and attest to these facts:
I understand that the Older Adult Protective Services Act, 35 P.S. 10225.101 requires applicants to undergo criminal background checks.
I have no history of, nor conviction for, violent crime and have never been dismissed from employment due to abuse of clients or residents.
I have not been convicted of any of the Prohibitive Offenses as listed on the reverse side of this page.

Further, by my signature below I authorize, without reservation, any party or agency contacted by Deer Meadows Retirement Community to furnish the above noted background inquiry information whether such request is made by Deer Meadows prior to or after any employment with them.

In the event that the above facts cannot be attested to, please provide an explanation here if you wish to be considered for employment.

Signature and Date:

Print Full Name:
Print Other Names Used and/or Known As:
Current Address (Number and Street Apt. City State Zip Code):


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