5440 Charlesgate Road,
Applicants requiring reasonable accommodation to the
application and/or interview process should notify us.
Do you have a temporary address?
Present (Temp) Address
Will you accept another position?
Available to work Weekends?*
Which type(s) of employment will you accept:
If under the age of 18, do you have a work permit?*
Have you ever applied to any Laurel facility before?*
Have you ever worked at any Laurel facility before?*
Do you have any friends or relatives working for this Laurel facility?*
List any friends or relatives working for this Laurel facility:
Do you limit your earnings due to Social Security or other reasons?*
Did you graduate High School?*
Did you graduate College?
Did you complete this training?
Did you serve in the Military?
Did you receive an honorable discharge?
Have you ever been convicted of a crime other than minor traffic violations?
List three references; Please include previous co-workers
I certify that all information I have provided in order to apply for and secure work with the Company is true, complete, and Correct.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be
sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the Company's service,
whenever it is discovered.
I expressly authorize, without reservation, the Company, its representatives, employees or agents to contact and obtain information
from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to
otherwise verify the accuracy of all information provided by me in this application, in my resume or in any job interview. I hereby
waive any and all rights and claims T may have regarding the Company, its agents, employees or representatives, for seeking, gathering
and using such information in the employment process and all other persons, corporations or organizations for furnishing such
information about me. I understand that employment is contingent on passing a criminal records check and drug test. I consent to
take a physical examination, and such further physical examinations as may be required by the Company at such times and places as
the Company shall designate. I understand that an offer of employment may be contingent on passing a physical examination which
relates to the essential duties I would be required to perform.
I understand that the Company may require me temporarily to work shifts other than the one for which I am applying and I agree to
such scheduling change as directed by my department head or the administrator of the facility. I understand that if my availability
status changes, it is my responsibility to notify my department head or the administrator of the facility.
I understand that the Company does not unlawfully discriminate in hiring or any other decision on the basis of race, color, sex,
height, weight, age, citizenship, national origin, ancestry, Vietnam era veteran status, familial status, marital status, pregnancy, childbirth
or related medical conditions, or on the basis of physical or mental disability unrelated to ability to perform the work required.
No question on this application is intended to secure information to be used for such discrimination.
I understand that if I am hired, my employment is "AT WILL". This means that I am free to resign at any time, with or without
cause and without prior notice, and the Company reserves the same right to terminate my employment at any time, with or without
cause and without prior notice, except as may be required by law. I understand that no supervisor or representative of the Company is
authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express
language are valid unless they are in writing and signed by the Company's president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and
that federal immigration laws require me to complete an I-9 Form in this regard.
DO NOT CLICK ACCEPT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
Laurel Health Care Company complies with applicable Federal civil rights laws and does not discriminate based on the basis of race, color, national origin, age, disability, or sex.
Resident Trust Fund Questions – firstname.lastname@example.org and 614-392-1932.
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