Application

If you are interested in seeking employment with Gowin Parc, please PRINT this page, complete the application and either bring it to our location at 300 Lerna Rd South in Mattoon or fax it to 217-234-3081.

APPLICATION FOR EMPLOYMENT
Gowin Parc of Mattoon                              Gowin Parc of Pana
300 Lerna Road South                               340 Illinois Route 29
Mattoon, IL 61938                                   Pana, IL 62557
(217) 234-3003                                            (217) 562-3004

FAX: (217) 234-3083 Fax: (217) 562-3081

EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
All persons should have the opportunity to be considered for employment without regard to their race, color, religion, national origin or ancestry, handicap or disability, sex, marital status, obligation to serve in the armed forces of the United States, citizenship, or any other characteristic protected by applicable federal or state law.

Date _______________________________
Name _____________________________________________________________________
                                Last                                First                                  Middle Initial
Address ______________________________________________________________________________
                                Street                                                                       City                         State                        Zip
Home Telephone ________________________________ Cell Phone ______________________________
Position Applied for ______________________________ Salary Desired___________________________
Are you applying for:          Full Time          Part Time (how many days? ________)    Temporary
Shift Preference:                   Day                   Evening           Night

AVAILABILITY	Mon	Tues	Wed	Thu	Fri	Sat	Sun
Preferred
Occasional Fill-in
Unavailable

Can you submit proof of legal employment authorization and identity? Yes     No
Are you 18 or older?    Yes           No
Have you ever been convicted of any crime other than a minor traffic violation?   Yes    No
A criminal conviction will not necessarily be a bar to employment. To help us evaluate your application, please describe the nature of the crime and your subsequent rehabilitation. __________________________
______________________________________________________________________________________
______________________________________________________________________________________
Have you ever been disciplined for resident abuse? Yes   No
Do you have relatives or friends employed by Gowin Parc? Yes   No       Name ________________
Have you ever been employed by Gowin Parc before?   Yes   No               Date _________________
How were you referred and why are you interested in working at Gowin Parc? _______________________ ______________________________________________________________________________________
______________________________________________________________________________________
Please describe any experience you have had working with the elderly or someone with Alzheimer’s Disease / Dementia ______________________________________________________________________________________
______________________________________________________________________________________
Employment History      Please provide all employment information for your past three employers

Most Recent
Employer _________________________
Position held _______________________
Address ___________________________
__________________________________
Phone ____________________________
Immediate Supervisor _______________
__________________________________
Dates employed
From ___________ to _______________
Salary
Start ___________end _______________
Job summary ______________________
__________________________________
__________________________________
Reason for leaving __________________
__________________________________
__________________________________
May we contact? Yes No
Comments _________________________
__________________________________

Employer _________________________
Position held _______________________
Address ___________________________
__________________________________
Phone ____________________________
Immediate Supervisor _______________
__________________________________
Dates employed
From ___________ to _______________
Salary
Start ___________end _______________
Job summary ______________________
__________________________________
__________________________________
Reason for leaving __________________
__________________________________
__________________________________
May we contact? Yes No
Comments _________________________
__________________________________

EDUCATIONAL HISTORY

School	Name and Address	Course of Study	Circle Last Year Completed	List Diploma, Degree(s) Obtained
High School			1 2 3 4
College(s)			1 2 3 4 5 6 7 8
Other

REFERENCES
Please list 3 references – these include persons in academic institutions, volunteer organizations, professional relationships, etc.
Not friends or relatives.
Name
1.
2.
3.
Address
Phone
Relationship/Years Known
AUTHORIZATION
I authorize investigation of all statements contained herein including a criminal background check and the references and employees listed herein to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from the utilization of such information.
In consideration of my employment I agree to conform to the rules and regulations of this company and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice at any time, at the option of either this company or myself. I also understand and agree that the terms and conditions of my employment may be changed with or without cause and with or without notice at any time by this company. I understand that no representative of this company, other than its Administrator, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.
I certify that I have read and understand the foregoing paragraphs. I further certify that all the information submitted by me on the application is true and complete to the best of my knowledge, and I understand that any false information, omissions, or misrepresentations of facts called for on this application may be cause for the denial of my application, or if I am employed, discharge at any time. As a condition of employment, I hereby consent to testing for drug and alcohol use, determined to be appropriate by management, either before being hired or at any time during my employment with this company.
Signature __________________________________________________________ Date ______________