Applicant Name:

Phone:    Social Security No.

Street Address:    E-mail

Building or Apartment #:    City:    State:    Zip:

How long have you lived here?    Date of Birth:

Position applying for:

Salary desired:    How many hours can you work weekly?

Can you work nights?     Yes     No

Employment desired:     Full-Time Only     Part-Time Only     Full- or Part-Time

Days/Hours available to work:

When can you start?

Do you have a driver's license?     Yes     No

What is your means of transportation to work?

Driver's license number:    State of issue:

Operator     Commercial     Chauffeur      Expiration Date:

Have you had any accidents during the past 3 years?     No     Yes    

Have you had any moving violations during the past 3 years?     No     Yes    

Please list two references other than relatives or previous employers.

Have you ever been in the Armed Forces?     Yes     No

Are you now a member of the National Guard?     Yes     No

Specialty:

Date Entered:    Discharge Date:

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

In exchange for the consideration of my job application by VINCENT VICTORIA VILLAGE ASSISTED LIVING, hereinafter called “the Company”, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the Company or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President / Vice President of the Company. Both the undersigned and Vincent Victoria Village may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of my employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.