THE GREENS AT CANNONDALE APPLICATION FOR EMPLOYMENT

List employment experience starting with the most recent or current employer. Include U.S. military service and schooling.
GENERAL INFORMATION
Name(Required)
MM slash DD slash YYYY
Address
If offered a position, are you able to submit documentation showing eligibility to work in the United States?
POSITION INFORMATION
Position applied for:
MM slash DD slash YYYY

LICENSING

Fill out only if you are applying for a position requiring a license or certification.
Do you have a nursing license issued by the State of Connecticut?
Has your license ever been suspended?
Do you have a CNA certificate issued by the State of Connecticut?
Do you have a Driver’s License?
Has your license ever been suspended?

EDUCATION
High School (or G.E.D. equivalent)
College or University
Vocational or Trade School
Other

EMPLOYMENT RECORD

List employment experience starting with the most recent or current employer. Include U.S. military service and schooling.
MM slash DD slash YYYY
MM slash DD slash YYYY
May we contact?

MM slash DD slash YYYY
MM slash DD slash YYYY
May we contact?

MM slash DD slash YYYY
MM slash DD slash YYYY
May we contact?

AN EQUAL OPPORTUNITY EMPLOYER
Have you worked for this company or any of its affiliates before?
Wilton Meadows Health Care Center
MM slash DD slash YYYY
The Greens at Greenwich
MM slash DD slash YYYY
The Greens at Cannondale
MM slash DD slash YYYY
Are you related to any current or past employee?

BACKGROUND INFORMATION
Have you ever been terminated, suspended, or asked to resign from any position?
For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations you have listed?

PROFESSIONAL REFERENCES
Have you signed or otherwise agreed to any non-solicitation, non-competition, or other similar post-employment restriction or agreement with your current or any prior employer?

AN EQUAL OPPORTUNITY EMPLOYER
ALL APPLICANTS PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING
  • I understand that, where permissible under applicable federal, state, or local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment and must receive a result consistent with company policy before being permitted to commence work.
  • I understand that, where permissible under applicable federal, state, or local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work.
  • I understand that, by signing the attached fingerprinting information form and background check consent form, I consent to a fingerprint-based national background check, before being permitted to commence work.
  • I understand that my listed references may be contacted and I agree not to hold Wilton Meadows Health Care Center or the Greens at Cannondale liable for inquiries regarding my experience, character, and reason for leaving any and all past employment.
  • I understand that employment is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.
  • I authorize The Greens at Cannondale and its representatives to contact my current and former employers (with the exception of my current employer, if I have marked “May we contact?” on page 2 of this application as “No”), schools, references, and other persons or organizations I have named in this application for the purpose of verifying the information I have provided. I release my current and former employers, schools, references, and other persons or organizations named in this application from any liability resulting from the information released. I authorize employers, schools, and other persons or organizations named in this application to provide any information or transcripts requested.
  • I hereby certify that, if employed, my employment with The Greens at Cannondale will not conflict with, violate, breach, or result in default under, any contract, agreement, or understanding that I am a party to or am bound by, including any non-solicitation, non-competition, or other similar post-employment restriction or agreement I have with any current or former employer, other than the contracts, agreements, covenants, or understandings I have disclosed in this application, if any.
  • I understand and agree that, if hired, my employment will be at will, which means employment is for an indefinite period of time and may be terminated by either party at any time, with or without cause, and with or without notice.
  • I certify that all of the above information is true and complete and I understand that any falsification or omission of information made by me may disqualify me from further consideration for employment or, if hired, may result in my termination at any time during the period of my employment, regardless of the amount of time that has passed.
  • I understand and agree that, if hired, my employment will be at will, which means employment is for an indefinite period of time and may be terminated by either party at any time, with or without cause, and with or without notice.
MM slash DD slash YYYY