United States Start Date

Jim Smith’s Employment Application

Application Date: 11/26/2024

Job Title: Housekeeper - Full Time

Job Location: Navarre

Personal Information

First Name: Jim

Last Name: Smith

Email: **********@*****.***

Contact Information

Cell Phone: 330-***-****

Home Phone: 330-***-****

Country: United States

State: OH

Address: 1639 derby ct sw

City: Canton

Postal Code: 44706

Application Questions

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General Information

Are you 18 years of age or older? Yes

Are you legally authorized to work in the United States? Yes Available Start Date: 11/27/2024

If referred by a current employee, please give employee name: Nick. Visneck Please choose the residency option that best fits: I have resided in Ohio for the past five years.

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Employment History

Please provide the following requested information regarding your employment history: Include military service assignments and volunteer activities. You may exclude organization names that include race, color, religion, gender, national origin, ancestry, age, disability or other protected status. Current or Most Recent Employer

Job Title: Setup

Employer Name: Cablecraft

City: Bolaver

State or Province: OH

Currently Employed? n/a

Start Date: 12/13/2019

End Date: 10/20/2024

Reason for Leaving: Trying to get a better job

Explanation: n/a

Rate of Pay: $17.25

Direct Supervisor: Richard

Company Phone: n/a

OK to contact? Yes

Responsibilities and Duties: Change over machines

2nd Previous Employer

Job Title: County lawn nursing home

Employer Name: Country lawn nursing home

City: Brewster

State or Province: OH

Currently Employed? n/a

Start Date: 11/22/1985

End Date: 10/08/2001

Reason for Leaving: Found better job

Explanation: n/a

Rate of Pay: $10.50

Direct Supervisor: Donna

Company Phone: n/a

OK to contact? Yes

Responsibilities and Duties: Dishwasher and keeping kitchen clean 3rd Previous Employer

Job Title: n/a

Employer Name: n/a

City: n/a

State or Province: n/a

Currently Employed? n/a

Start Date: n/a

End Date: n/a

Reason for Leaving: n/a

Explanation: n/a

Rate of Pay: n/a

Direct Supervisor: n/a

Company Phone: n/a

OK to contact? n/a

Responsibilities and Duties: n/a

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Education/Training

What is your highest level of education completed? High School/GED Name of Institution(s): n/a

Graduate? Yes

Major(s): Math

Degree(s) or Certification(s): Na

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Professional Registration, Licensure, or Certification Certificate/License 1

Name: n/a

State: n/a

Expiration Date: n/a

Licensing Agency: n/a

Reviewed By: n/a

Certificate/License 2

Name: n/a

State: n/a

Expiration Date: n/a

Licensing Agency: n/a

Reviewed By: n/a

Have you ever been licensed in another state? No

If so, what state, when, and what is the current status of that license? n/a Have you ever had a professional license, registration, or certification restricted, suspended or revoked for any reason? N/A

If YES, please identify the type of license, registration, or certification, the reason why it was restricted, suspended or revoked, and the final disposition of the matter: n/a Have you ever had a finding on the nurse aide registry? No

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Additional Questions

Have you ever been convicted of a misdemeanor or felony? No If YES, please identify conviction: n/a

Have you ever had a conviction sealed or expunged? No Have you ever been found guilty of abusing, neglecting or mistreating residents by a court of law? No Have you ever been dismissed or asked to resign from a position? No Have you ever worked for an Altercare facility, an Absolute company or Avalon Foodservice before? No If YES, when and which facility? n/a

How Did you hear about us? Indeed

If 'Other' please specify. n/a

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References

Please list two professional references.

1st Reference

Name: n/a

Company: n/a

Relationship: n/a

Phone: n/a

Email: n/a

Years Known: n/a

2nd Reference

Name: n/a

Company: n/a

Relationship: n/a

Phone: n/a

Email: n/a

Years Known: n/a

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Long Term Care Worker Background Check and Attestation In connection with my application for employment, I understand that investigative background inquiries are to be made including, but not limited to consumer credit, social security number, criminal and motor vehicle records. These reports may contain information about my character, work habits, performances and experience along with reasons for termination of past employments. Further, I understand that information will be requested from various Federal, State and other agencies which maintain records concerning my personal history.I authorize, without reservation, any party or agency contacted to release any information requested and release all parties involved from any liability and responsibility for doing so. This authorization and consent shall be valid in original, fax or copy form.By typing my name below, I consent to the submission of a request for a criminal records check for long-term care workers. This request will be submitted by the company of employ. I also attest to the following: 1. That I have not been convicted of, or pleaded guilty or no contest to any disqualifying offense. 2. That I understand and agree that if I am found to have a record of any of those crimes, or if I am convicted or plead guilty to any of those crimes in the future, I will not be hired for a position that involves providing direct care to older adults or, if I have already been hired, my employment will be terminated. 3. That I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment. Agreement: Yes

Applicant Signature: Jim smith

Date: 11/26/2024

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Applicant's Statement

I certify that my answers to all questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application or during the pre-employment process may be grounds for my immediate termination. Acceptance: Yes

Signature: Jim smith

Check the box below if you would like to receive text messages from the company regarding your status in the hiring process. Data rates may apply. I am happy to receive text messages from Altercare Integrated Health Services. By checking this box, you acknowledge and consent to terms of the privacy policy which applies to the applicant tracking service being offered by Paycor on behalf of Altercare Integrated Health Services. The privacy policy offers an explanation of how and why your data will be collected, how it will be used and disclosed, how it will be retained and secured, and what legal rights are associated with that data (including the rights of access, correction, and deletion). The policy also describes legal and contractual limitations on these rights. The specific rights and obligations of individuals living and working in different areas may vary by jurisdiction. I have read and agree to this statement

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