Employment Application Online – BROWNWOOD LIFE CARE CENTER

Name *

First

Middle

Last

Address *

City, State, Zip *

Phone Number (With Area Code) *

Email *

Date Available *

Social Security Number

Desired Salary

Desired Shift

Position Applying For

Type of Employment Desired

How Did You Hear About Us?

Have You Been Employed at Brownwood Before?

If so, what dates?

Are You Authorized to Work In the US?

Are there any reasons why you would be unable to perform the tasks involved in the position for which you are applying? If yes, please state these reasons.

Reasons

Have you ever been convicted of, pleaded guilty to, or served probation for any crime (excluding minor violations), including DWI/DUI?

If Yes, state the offense, location, date, and disposition.

Do you have obligations or other reasons that would limit your ability to travel or work overtime?

If Yes, Explain.

High School

Please list the name of the high school you attended.

Address

High School Address

Did you Graduate?

GED Date

If you received your GED, please list the date you received it.

College

Address

Address of College you attended.

Did You Graduate?

Degree

Graduation Date

Other

Did You Graduate?

Degree

Graduation Date

References

Please list First and Last Name, Address, Phone Number, and Relationship for THREE References.

Previous Employment-Company Name

Address

City, State, Zip

Phone with Area Code

Job Title

Supervisor

Responsibilities

Starting Salary

Ending Salary

Start Date

End Date

Reason for Leaving

May We Contact Your Previous Supervisor for a reference?

Company Name

Address

Phone with Area Code

Job Title

Supervisor

Responsibilities

Starting Salary

Ending Salary

Start Date

End Date

Reason for Leaving

May we contact your previous supervisor for a reference?

Company Name

Address

Phone with Area Code

Job Title

Supervisor

Responsibilities

Starting Salary

Ending Salary

Start Date

End Date

Reason for Leaving

May we contact your previous supervisor for a reference?

Please list your skills and abilities.

I certify that my answers to the preceding questions are true and correct without any consequential omission of any kind whatsoever. I understand that if I am employed by Brownwood Life Care Center, any false, misleading, or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge. I hereby authorize Brownwood to contact any company or individual it deems appropriate to investigate any and all employment history, character and qualifications and I give my full and complete consent to their revealing any and all inforation they wish as a result of this investigation. In addition, I hereby waive any right to bring any cause of action against those individuals for defamation, invasion of privacy, or any other reason because of their statements. I agree that if I am employed, I will abide by all the rules and regulations of the Company. I understand that the taking of drugs and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to enter into any written or verbal contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that any employment is "at-will" and may be terminated by myself or by the Company at any time for any or no reason at all with or without prior notice. *

Please type your name in the space above as this takes the place of your signature. Please put the date you are signing next to your signature.

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