Application

All applicants selected for employment with Brighter Living Adult Day must satisfactorily pass a pre-employment drug screen and criminal background check to be eligible for employment. Brighter Living Adult Day is an Equal Opportunity and Affirmative Action Employer. This agency only hires individuals who are authorized to work in the United States. This application is subject to the conditions set forth in the Certification and Agreement section on the last page.

PLEASE COMPLETE APPLICATION IN FULL

Full Name

Current Address

City

State (required)

Zip

Phone Number

EMERGENCY CONTACT

In case of an emergency, please contact:


Source of Referral
Walk-inNewspaperInternetYellow PagesOther

Have you ever been convicted of a felony or a misdemeanor, or have you ever plead no contest to any criminal charges?* (Provide date, city, state and an explanation for all yes responses. Use additional paper if necessary.)

*Criminal conviction is not an absolute bar to employment but will be considered in relation to specific job requirements.

Do you have any restrictions or physical limitations that may prevent you from performing any duties listed on
Job description for the position in which you are applying?

If so, please explain:

Have you or any relatives ever been employed by A Brighter Living? If yes, who and what is their relationship to you?

EDUCATION
Have you graduated from High School or completed the GED equivalent?

List all degrees that you have received. List your HIGHEST DEGREE FIRST. Do NOT list degrees that you are currently working toward (see below)

Major:
Degree:
School:
Graduation Date

Are you currently enrolled?

Last Year Attended:
Major:

Check last level of school completed:
UndergraduateFreshmanSophomore JuniorSeniorGraduate1st year2nd year3rd year4th year

LICENSE/REGISTRATION/CERTIFICATION
Please list all professional licenses, registrations, and certifications.
Lic.Reg./Cert. Type

License Number

State

Expiration Date

Please indicate which of the following credentials you currently hold.

CPR:
Expiration Date

BCLS:
Expiration Date

ACLS:
Expiration Date

Please indicate which of the following certification you currently hold.
CCRN:
Expiration Date

CEN:
Expiration Date

CHEM:
Expiration Date

Critical Care Course:
Expiration Date

Do you have any pending restrictions and/or suspensions on your current professional license/registration that would restrain
You from performing in this position?

Have you ever been refused professional licensure, or had a license / registration suspended or revoked?

EMPLOYMENT HISTORY

Start with your most recent employment, record of all employment and reasons for periods of unemployment.

Company Name

Address

City

State

Zip Code

Phone Number

Type Of Business

Supervisor's Name

Dates Employed

Date Left

Title And Duties:

Reason for leaving:

Starting Salary:

Final Salary:

Company Name

Address

City

State

Zip Code

Phone Number

Type Of Business

Supervisor's Name

Dates Employed

Date Left

Title And Duties:

Reason for leaving:

Starting Salary:

Final Salary:

Company Name

Address

City

State

Zip Code

Phone Number

Type Of Business

Supervisor's Name

Dates Employed

Date Left

Title And Duties:

Reason for leaving:

Starting Salary:

Final Salary:

Provide THREE **WORK-RELATED** REFERENCES

Name

Occupation or Title

Firm Name & Address

Phone Number

Years Known:

Name

Occupation or Title

Firm Name & Address

Phone Number

Years Known:

Name

Occupation or Title

Firm Name & Address

Phone Number

Years Known:

WORK AVAILABILITY

Current Salary:

Minimum Salary:

Date of Available Work:

MARK ALL THAT APPLY:
Full-TimePart-TimeOn-CallWork WeekendsRotating ShiftsDaysEveningsNights

CERTIFICATION AND AGREEMENT
I certify that the information I provided in this application is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in this application disqualifies me from further consideration, or, if I am employed, is sufficient cause for dismissal. I understand that any alteration of this application’s content or form may be considered cause for disqualification and/or termination.

I authorize investigation of all statements contained in this application and understand that I may be required to provide verification (diploma, license, transcripts, type tests, etc.) of information contained in this application.

I authorize any and all persons, companies or agencies to release to Brighter Living Adult Day any and all information they may have which is relevant to the application process. I also release all such parties from any liability that may result from furnishing information to the Agency.

I understand that to be considered as a formal applicant, the position for which I am applying must be specifically identified as open, and recruitment for the position going on at the time this application is received by the Human Resources Department.

I understand that, if I have not worked for Brighter Living Adult Day for over one year, that I may be asked for additional references and employment information.

I understand that if I am employed with Brighter Living Adult Day, my employment will be at-will. As such, it can be terminated by me or by Brighter Living Adult Day with or without advance notice, at any time, and for any reason not prohibited by law. I agree that if I am employed with this agency, I will review the information contained in the General Information Handbook.

I understand that any employment offer is contingent upon the following: (1) producing documents establishing my eligibility to work in the United States; (2) satisfactorily passing the pre-employment drug screen, criminal background and reference checks; and (3) complying with the pre-employment application procedures.

By signing and submitting this application to Brighter Living Adult Day, I acknowledge that I have read the certification and agreement and agree to abide by its terms.

Signature