Employment Application

Good Shepherd Community/Ecumenical Retirement Center (ERC, Inc.) prides itself on being an Equal Opportunity Employer. We will not discriminate in employment because of race, color, religion, sex, national origin, disability or age.

All information obtained within this application will be held in strict confidence, subject to applicable law.

• Please complete all applicable sections and sign electronically at the bottom.
• We are a drug-free workplace. Screening tests for illegal drug use will be required as a condition of employment.
• Travel may be required for certain positions

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email Address*

Date Available*

Position Applying For:

Desired Salary:

Are you a U.S. citizen?*

Yes
No

If no, are you authorized to work in the U.S.?*

Yes
No
N/A

Have you worked for ERC, Inc. before?*

Yes
No

If yes, when and where?*

If under 18 years of age, can you provide proof of eligibility to work?*

Yes
No
N/A

Have you ever been convicted of a misdemeanor or felony?*

Yes
No

If yes, please explain:*

Educational Background

High School Graduate or Equivalent?

Yes
No

College/University

Trade/Profession

List any skills, experience, or other qualifications which you feel would assist you in performing the duties of the position you are applying for.

Previous Employment

List your current and former employers below. Please include the employment related to the position to which you are applying. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.

Employer 1

Company/Employer

Business Phone

Company Contact

First Last

Hire Date

Departure Date

Position(s) held:

Reason for Departure:

Duties

May we contact this employer?

Yes
No

Employer 2

Company/Employer

Business Phone

Company Contact

First Last

Hire Date

Departure Date

Position(s) held:

Reason for Departure:

Duties

May we contact this employer?

Yes
No

Employer 3

Company/Employer

Business Phone

Company Contact

First Last

Hire Date

Departure Date

Position(s) held:

Reason for Departure:

Duties

May we contact this employer?

Yes
No

Does the position you are applying for require driving?

Yes
No

NOTE: If you are selected for an interview, you are required to present a copy of your driving record that is not more than 4 weeks old. After being hired, a copy of this driving record will be placed into your personnel file and an annual update will be required.

Agreement

False information given or implied on an application form is grounds for immediate dismissal without further notice.

I hereby state that all information provided is accurate and may be verified by you. I agree that I may be discharged if ERC, Inc. at any time learns of falsification or material omission in the information provided on this application form and related documents. I hereby understand and acknowledge that, unless otherwise defined by application law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

Consent*

I agree

Electronic Signature ---- Applicant agrees that the signature appearing on this application is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility. ERC, Inc. and its affiliates, successors, and assigns may contact my former employer in connection with the consideration of my employment with them. All references are hereby authorized to release all information that they may have relevant to my employment with them. I hereby release ERC, Inc. and its affiliates, successors, and assigns, and all references from any liability that might be claimed because of information provided by such references.

Electronic Signature*

First Last

Date of Agreement*

Please Note

CONSIDERATION OF EMPLOYMENT WILL NOT BE GIVEN TO ANY APPLICANT WHO DOES NOT SIGN THE ABOVE STATEMENT.

NOTE: Additional personal information will be required to complete benefit forms after being hired.

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Email

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