Online Application Form Please complete the online application form below. Step 1 of 6 16% It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, national origin, marital status, disability or any other classification in accordance with Federal, State, and Local statutes, regulations and ordinances.Contact InformationName(Required) First Last Phone(Required)Email(Required) Job InformationPosition Requesting(Required) Community(Required) Date You Can Start(Required) Month Day Year Desired Pay Rate Are you authorized to work in the US?(Required) Yes No Are you at least 18 years or older?(Required) Yes No Have you ever applied here before?(Required) Yes No When did you apply?(Required) MM slash DD slash YYYY Job RequirementsIf required, will you work?Rotating Shift(Required) Yes No Overtime(Required) Yes No Saturdays(Required) Yes No Sundays(Required) Yes No Application InformationCurrent Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EducationHigh SchoolNameCity, StateYears AttendedCollege / UniversityNameCity, StateYears Attended Add RemoveOtherNameCity, StateYears Attended Add RemoveHave you been charged/convicted of any felony and/or misdemeanor?(Required)If yes, Please list charges/convictions of any felony and/or misdemeanor. In accordance with company and state regulations, this information will be reviewed. A conviction will not disqualify an applicant for employment. Omitting a conviction disqualifies an applicant for employment with the company. Yes No List(Required)Description of incidentChargeDateLocation (City & State)Status Add Remove Skills/License/CertificateSkills/License/Certificate First Aid QMAP ServSafe CNA Other First Aid Certification Expiration Date(Required) Month Day Year QMAP Certification Expiration Date(Required) Month Day Year ServSafe Certification Expiration Date(Required) Month Day Year CNA Certification Expiration Date(Required) Month Day Year Other(Required)Please list any other relevant training and experience.Emergency Contact(Required)NameRelationshipPhoneReferencesPlease list three references that are not related to you.Reference 1(Required)NameRelation/TitlePhoneEmailReference 2(Required)Please list three references that are not related to you.NameRelation/TitlePhoneEmailReference 3(Required)Please list three references that are not related to you.NameRelation/TitlePhoneEmail Employment History | Most Recent EmployerEmployment HistoryEnter your last 3 jobs. Company Name Job Title Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Employment GapsPlease account for any gaps in employment including military service and any periods of unemployment. Referral SourceReferral Source(Required)Please enter below how you heard about the position.Newspaper - Name of paperWebsite - Enter web addressEmployee - Enter employee nameOther - Please explain. Add Remove Upload ResumeYou can upload your complete resume here.Accepted file types: pdf, doc, docx, jpg, gif, Max. file size: 256 MB.Consent(Required)I have read, agree and consent to all statements in this application for employment. I certify that the information contained in this application is correct and complete. I understand that any misstatement or omission of information will result in denial of employment or discharge. I authorize the references listed above to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing any information to AltaVita Memory Care Centre. I consent to pre & post-employment drug screens as required by the company. I understand that this application does not constitute a contract of employment nor guarantees employment.CAPTCHA Δ
