Name:

What rate of pay do you expect to receive if employed?

EDUCATION

EMPLOYMENT

List all employment, including any temporary position(s) for the past ten years. List current or most recent employer first. Use additional sheets if necessary.

SeniorsPlus provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require an accommodation in the application process, please advise the SeniorsPlus human resources manager directly.

PLEASE READ AND SIGN BELOW:

I understand and agree that if I am hired, my employment with SeniorsPlus will be terminable “at-will.” As an at-will employee, I understand and agree that I have the right to terminate my employment with the Agency at any time, for any reason, with or without notice, with or without cause, and that the Agency retains the same rights. If I am hired, I understand that all benefits, policies and procedures may be changed by the Agency at any time, with or without notice. I understand that this application form, any and all policies, practices, and procedures of the Agency, and all other communications provided or distributed to me by the Agency, whether written or verbal, before hire or after I am employed, do not constitute or supplement any contract of employment. I further understand that no agent, employee, or representative of the Agency has the authority to make any promise or agreement contrary to the foregoing, unless it is in writing and signed by the CEO of the Agency.

I authorize the Agency to investigate, verify and discuss all information set forth in my application, by contacting my prior employers and other references set forth above, and by any and all other means authorized or permitted by law. 

I authorize the Agency to request and obtain job-related information such as motor vehicle driving records, and make any other inquiries as to my character, reputation and ability as necessary for the Agency to consider and evaluate my application for employment. I authorize any entity or person named in this application to provide the Agency with any and all information in their possession, custody, or control regarding me, whether or not it is in their records, and to provide the Agency with information that may be requested by the Agency to arrive at an employment decision. I hereby release and agree to hold harmless the Agency and its employees and agents from any and all claims that may arise as a result of taking any actions described herein. In addition, I hereby release and agree to hold harmless any and all individuals and entities that provide any information concerning me whether orally or in writing, in response to a request for such information from the Agency. A photocopy of this authorization shall be deemed as valid as the original and this authorization shall remain valid and in full force and effect for a period of two years from the date written below.

If I am employed by the Agency, I shall comply with all policies, rules and regulations implemented by the Agency. I recognize that violation or non-compliance with any such policies, rules and regulations, or inappropriate or improper conduct or performance, may result in discipline up to and including termination of employment.

I hereby certify that the facts set forth above in my employment application are true and complete to the best of my knowledge. I understand that any omissions or false or misleading statements in this application or in interviews or other aspects of the hiring process may result in my disqualification from further consideration for employment or, if already employed, such information may be grounds for the immediate termination of my employment.

I have read the above and understand it.

SeniorsPlus is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, gender, sexual orientation, gender expression, gender identity, genetic information, family caregiver status, marital status, pregnancy, national origin, ancestry, citizenship, age, disability, military status, veteran status, disability, or other status protected by law.

Please let us know if you need assistance in the application and/or interview process.

CONSUMER REPORT DISCLOSURE FORM/AUTHORIZATION

Please Read Carefully Before Signing the Authorization

In connection with your application for employment and if you are employed, in connection with your continued employment with SeniorsPlus (the “Company”), the Company may obtain and rely upon one or more consumer reports and/or investigative consumer reports (collectively “Consumer Report”) regarding you for employment purposes. Information that is commonly included in a Consumer Report includes, but is not limited to, information about character, general reputation, criminal record, motor vehicle record, credit history, mode of living and other personal characteristics relevant to employment at the Company. An investigative consumer report involves personal interviews with sources such as friends, neighbors and associates. Your employment with the Company is conditioned upon the satisfactory results of any Consumer Report(s) regarding you. If the Consumer Report(s) is (are) not satisfactory, as determined by the Company, in its sole discretion, you may be denied employment or your employment with the Company may be terminated. You have the right to request and receive a written statement explaining the nature and scope of any investigation which is requested with respect to you, as well as the name, address, and telephone number of the nearest unit designated to handle inquiries of each consumer reporting agency issuing an Consumer Report about you. The Company will provide this information to you within five (5) business days of receiving your request or within five (5) business days of the Company requesting the report, whichever is later. You also have the right to request and promptly receive copies of any Consumer Report about you from any credit reporting agency issuing such a report.

Under the Fair Credit Reporting Act (“FCRA”), before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization.  Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

AUTHORIZATION

I have read and understand the foregoing Disclosure, and authorize SeniorsPlus via its Consumer Report vendor to obtain and rely upon consumer reports or investigative consumer reports concerning me.  By my signature below, I authorize SeniorsPlus via its Consumer Report vendor to obtain any such reports and to share the information received with any person involved in their decision about me.  I also consent to have any legally required notices sent electronically.