Full Name *

Phone *

Address *

State *

City *

Postal code *

Email *

Date of Application *

Employment Position

How did you hear about this position? *

What days are you available for work? *

What hours or shifts are you available for work? *

If needed are you available to work overtime? *

On what date can you start working if you are hired? *

Do you have reliable transportation? *

Yes

Working on it

Salary Desired *

Personal Information

Do you have any friends or relatives working for Village Forest Care Cottage? *

Yes

If yes, state name and relationship:

Are you 18 years of age or older? *

Yes

Are you a U.S. citizen or approved for work in the United States?

Yes

What document can you provide as proof of citizenship or legal status?

Personal Information, continued

Will you consent to a mandatory controlled substance test? *

Yes

Do you have any conditions which would require job accommodation? *

Yes

If yes, please describe accommodations required below.

Have you ever been convicted of a criminal offense (felony or misdemeanor)? *

Yes

Personal Information, continued

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Village Forest Care Cottage complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )

Education and Training

High School

Location (City, State)

Name

Year Graduated

Degree Earned

Education and Training continued

College/University

Name

Location (City, State)

Degree Earned

Year Graduated

Education and Training continued

Vocational School/Specialized Training

Name

Location (City, State)

Year Graduated

Degree Earned

Previous Employment

Employer Name:

Job Title:

Supervisor Name:

Employer Address

Code: Employer

City, State and Zip

Telephone: Dates

Employed: Reason for Leaving

Previous Employment continued

Employer Name:

Job Title:

Supervisor Name:

Employer Address

City, State and Zip

Code: Employer

Telephone: Dates

Employed: Reason for leaving:

Previous Employment continued

Employer Name:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip

Code: Employer

Telephone: Dates

Employed: Reason for leaving:

References

Please provide 2 personal and professional reference(s) below:

Reference

Contact Information

Reference

Contact Information

AT-WILL EMPLOYMENT

The relationship between you and the Village Forest Care Cottage is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Village Forest Care Cottage. No representative of Village Forest Care Cottage has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Signature: *

Dated *