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Job Application

Please apply by filling out the details below. The Cottage Senior Living is committed to providing an equal employment opportunity for all persons regardless of race, color, national origin, religion, sex, disability, age, citizenship status, genetic information, sexual orientation, AIDS/HIV, gender identity, wage discrimination, or any other status protected by law (“Protected Classes”). *Required
About You

Name*
First Middle Last
Address*
Street Address City State ZIP Code
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
Position applying for

Position applying for*
- Caregiver
- Med Cart
- LPN
- RN
- Cook
- Head Cook
- Housekeeping
- Administrator
- Assistant Administrator
- Activities
- Maintenance
Please note that all positions listed below may not be currently available, but feel free to submit an application, as we may contact you for further conversation.
Type of position*
- Full-Time
- Part-Time
- Temporary
- Other
Other position*
Shifts you are willing to work*
- 6:00am - 2:00pm
- 2:00pm - 10:00pm
- 10:00pm - 6:00am
Date you are available to begin*
MM slash DD slash YYYY
Education

Education*
- High School
- Military
- Associate Degree
- Bachelor's Degree
- Master's Degree
- Professional Degree
- Doctorate Degree
- Other
Please select highest level completed
Other Education
List of Schools Attended (Include High School, College Prep, College)*
School Name Major/Specialization

Please also list any majors
Training*
Skills or courses (medical, computer, management, etc.)
Are you a certified nurse's aid?*
- Yes
- No
If yes, in what state?*
Have you completed the Unlicensed Assistive Personnel (UAP) to pass medications?*
- Yes
- No
Employment Information

Are you currently employed?*
- Yes
- No
If yes, may we contact them?*
- Yes
- No
Employer #1
Employer #1 (Most Recent)*
First Middle Last
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Starting Salary*
Ending Salary*
Duties Performed*
Reason for Leaving*
Have an additional employer to add?*
- Yes
- No
Employer #2
Employer #2*
First Middle Last
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Starting Salary*
Ending Salary*
Duties Performed*
Reason for Leaving*
Have an additional employer to add?*
- Yes
- No
Employer #3
Employer #3*
First Middle Last
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Starting Salary*
Ending Salary*
Duties Performed*
Reason for Leaving*
Personal References

Please List Three (3) Personal References

Other than employers listed above. Please list reference names, addresses, phone numbers and company (if applicable).
Reference #1
Street Address Address Line 2 City State ZIP Code
Reference #2*
Street Address Address Line 2 City State ZIP Code
Reference #3*
Street Address Address Line 2 City State ZIP Code
How did you hear about us?*
Other*
Upload Your CV (Not Required)
Upload Your CV (Not Required)
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 1.
Certification and Release
I certify that the answers given by me to the foregoing questions and the statements made by me are completed and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in the rejection of my application or discharge at any time during my employment. I authorize the employers, schools, or persons named above to provide information regarding my employment, education, character, and qualifications. I also authorize any company and/or its agents including consumer reporting bureaus or investigative agencies to verify any information, including but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and herby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature*
Please Note:

In order to complete the application process you may be asked to provide your social security number at a later date. If so, you will be contacted by a team member directly to obtain this information.
Comments
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