application

application 1505 Carpenter Road SE ~ Lacey, WA 98503
(360) 491-1765 ~ Fax: (360) 459-9472
Application for Employment

You may submit your resume to Human Resources / Personnel or you may fill in this application form.
If you prefer to e-mail your resume, please include a cover letter. [ MS Word only or copy and paste onto E-mail]
It is the policy of Roo-Lan Healthcare Center to provide equal employment opportunities without regard to race, color, sex, age, creed, religion, marital status, national origin, veteran status, the presence of any sensory, mental or physical handicap, or other reason prohibited by applicable Local, State, or Federal Law.

Answer every question which pertains to the position for which you are applying.

Position Applied For
First Name MI Last Name
Social Security No. Telephone No.
Address City, State, Zip Code
Are you 18 years of age or older? Yes
If under 18 years old, do you have a work permit? Yes No
Do you have any relatives employed by Roo-Lan Healthcare Center? If yes, list name(s) and relationship:

Have you previously worked for Roo-Lan Healthcare Center? If yes, list dates and title worked at Roo-Lan
Have you previously applied for a job with Roo-Lan Healthcare Center? If yes, please indicate when:
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration status will be required upon employment.) Yes No
What shift can you work?
Full Time Temporary Part Time On-Call Overtime Weekends
Day Shift (6:30 am to 3:00 pm) Evening Shift (3:00 pm to 11:00 pm) Night Shift (11:00 pm to 7:00 am)
Please specify any problems you may have meeting the work schedule and/or days available to work:

After reviewing the job description for which you are applying, are you able to perform the essential functions? If not why not? and what accommodations would permit you to perform the essential functions of the job?

Educational Record

School:
Location Graduate?
Yes No Degree Received & Years Attended

College
Location
Graduate?
Yes No

Degree Received & Years Attended

Other School:
Location
Graduate?
Yes No

Degree Received & Years Attended

Other
Location
Graduate?
Yes No

Degree Received & Years Attended

Do you have any other licenses or certifications which would be useful for the position you are applying? If yes, please list and explain
Do you have military service experience that would be relevant to the job(s) for which you are applying? If Yes, explain:
Are you engaged in an outside activity or business that could be considered a conflict of interest with this facility, or with the interest of its client? No If yes, please describe
Within the past seven (7) years, have you been convicted of or pleaded no contest to a criminal offense, or been released from prison for any criminal offense? No Yes If Yes, Please describe: Conviction of such a crime will not necessarily bar you from employment with Roo-Lan Healthcare Center. If yes, indicate the nature of offense, date, court, and disposition: [Note: the Washington State Patrol has special criminal record reporting requirements that must be satisfied.] Are you currently charged with an unresolved criminal charge? [type in "Yes" or "No"] Have you been charged with a crime that has not yet resulted in a plea of guilt, court trial, or a dropping of the charge? Yes No [Note:] A "Yes" answer will not automatically disqualify you from employment. If yes, please explain fully

Employment History

Employer's Name
Employer's Address
Employer's Telephone No.
Dates Employed
Your Title & Salary Primary Duties

Reason for Leaving

. .

2 Employer's Name

Employer's Address

Employer's Telephone No.

Dates Employed

Your Title & Salary
Primary Duties

Reason for Leaving

. .

3 Employer's Name

Employer's Address

Employer's Telephone No.

Dates Employed

Your Title & Salary
Primary Duties

Reason for Leaving

. .

4 Employer's Name

Employer's Address

Employer's Telephone No.

Dates Employed

Your Title & Salary
Primary Duties

Reason for Leaving

. .

5 Employer's Name

Employer's Address

Employer's Telephone No.

Dates Employed

Your Title & Salary
Primary Duties

Reason for Leaving

. .

6 Employer's Name

Employer's Address

Employer's Telephone No.

Dates Employed

Your Title & Salary
Primary Duties

Reason for Leaving

. .

Any additional work history may be sent through email after completing this application. Be sure to add your First and Last name, along with your SS# to assure additional information is attached to application

Please list Licenses and professional certifications related to the position which you are applying
Other Licenses

State any additional information you feel you may be helpful to us in considering your application

Please include personal or professional references below [Name, Address & Telephone Number:
Reference #1
Reference #2
Reference #3

You have completed our application form.
Please read the following before submitting application

Application Acknowledgment

Please carefully read the following before submitting your application. Upon submitting Application, I acknowledge the following: Roo-Lan Healthcare Center is an "at-will" employer. This means that in the event I am hired as an employee for Roo-Lan Healthcare Center, my employment and compensation can be terminated, with or without notice at any time, at the option of either Roo-Lan Healthcare Center or myself. I understand that no representative of Roo-Lan Healthcare Center (other than the Administrator) has the authority to enter into any agreement of employment for any specified period of time, or to make any agreement contrary to the foregoing. Any such requirement must be clearly identified as a written contract. I certify that the information given by me to Roo-Lan Healthcare Center on this electronic application for employment and through a hiring process is true and complete to the best of my knowledge. I understand that I will need to reapply on a 'real' application for signature purposes. I understand that a drug screening will be done prior to being hired. I understand that if I am employed, discovery that I gave false or misleading information may result in immediate dismissal. I authorize Roo-Lan Healthcare Center to solicit information regarding background information, and to contact any and all prior employers or other references I have listed on my application. I hereby release all parties and persons connected with any such request for information from all claims, liabilities, and damages for any reason arising out of furnishing such information. If employed, I release Roo-Lan Healthcare Center from any liability for future references it may provide regarding work history at the facility. I certify that I am not engaged in any outside activity or business that could be considered in conflict with Roo-Lan Healthcare Center's interest or those of its clients, nor will I become engaged in such activity or business if employed. If employed, I further agree that if Roo-Lan Healthcare Center advances any paid leave before it has accrued, or advances or loans to me any money during the course of my employment, or if I lose, damage, or fail to return any property of Roo-Lan Healthcare Center, Roo-Lan is authorized to deduct from my wages sufficient funds to repay such loans or advances or to replace its property. If I am applying for a position which may have unsupervised access to vulnerable adults as described in RCW 43.43.830, as part of my application process, I understand that I may be asked to disclose any history I may have of convictions against children or other persons; or crimes related to abuse or financial exploitation of vulnerable adults. I understand that I may be hired on a conditional basis, pending completion of a background investigation by the state patrol. I understand that as a condition of my employment, I must provide documentation to prove identity and eligibility to work in the United States by presenting any of the several documents as defined in INS Regulations 8 CFR �27a.2 (b) (1) (v). A complete list of all possible documents for proving eligibility to work is available in the administrator's office

School: Location	Graduate? Yes No	Degree Received & Years Attended
College Location	Graduate? Yes No	Degree Received & Years Attended
Other School: Location	Graduate? Yes No	Degree Received & Years Attended
Other Location	Graduate? Yes No	Degree Received & Years Attended

Employer's Name Employer's Address Employer's Telephone No. Dates Employed Your Title & Salary	Primary Duties Reason for Leaving
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2 Employer's Name Employer's Address Employer's Telephone No. Dates Employed Your Title & Salary	Primary Duties Reason for Leaving
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3 Employer's Name Employer's Address Employer's Telephone No. Dates Employed Your Title & Salary	Primary Duties Reason for Leaving
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4 Employer's Name Employer's Address Employer's Telephone No. Dates Employed Your Title & Salary	Primary Duties Reason for Leaving
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5 Employer's Name Employer's Address Employer's Telephone No. Dates Employed Your Title & Salary	Primary Duties Reason for Leaving
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6 Employer's Name Employer's Address Employer's Telephone No. Dates Employed Your Title & Salary	Primary Duties Reason for Leaving
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