Senior Monongalians, Inc. Employment Application

PLEASE READ THE FOLLOWING BEFORE COMPLETING OUR APPLICATION:

____________________________________, I have read the above statements.

Signature of Applicant

SENIOR MONONGALIANS, INC.

P.O. BOX 653

MORGANTOWN , WV 26505

APPLICATION FOR EMPLOYMENT

FEDERAL AND STATE LAWS PROHIBIT DISCRIMINATION IN EMPLOYMENT
BECAUSE OF SEX, AGE, RACE, COLOR, RELIGIOUS CREED, MARITAL STATUS,
NATIONAL ORIGIN, ANCESTRY, CITIZENSHIP, LIABILITY FOR SERVICE IN
THE ARMED FORCES OF THE UNITED STATES OR DISABILITY OR ANY
OTHER PROTECTED CLASSIFICATION

DATE: _____________________

PERSONAL INFORMATION TELEPHONE:
(______) ______ - ________

AREA NUMBER

NAME__________________________________________________________________

FIRST MIDDLE INITIAL LAST

PRESENT ADDRESS_____________________________________________________

STREET CITY STATE ZIP CODE

HAVE YOU EVER WORKED UNDER ANOTHER NAME? YES______ NO______

IF YES, WHAT NAME OR NAMES? _______________________________________

HAVE YOU EVER WORKED FOR SENIOR MONONGALIANS, INC. BEFORE?

YES_____ NO_____ IF YES, DATES OF EMPLOYMENT AND REASON FOR
LEAVING_______________________________________________________________

ARE YOU 18 YEARS OF AGE OR OLDER? YES ______ NO ______

ARE YOU EITHER A U.S. CITIZEN OR AN ALIEN WHO HAS THE LEGAL RIGHT
TO REMAIN AND WORK ING THE U.S.? (YOU WILL BE REQUIRED TO FURNISH
PROOF OF LAWFUL WORK STATUS IF YOU ARE EXTENDED A JOB OFFER.)
YES ______ NO ______

HAVE YOUR EVER BEEN CONVICTED OF A CRIME? YES ______ NO ______

IF SO, PLEASE DESCRIBE FULLY THE CRIMINAL CONVICTION(S), LISTING
THE NATURE OF THE OFFENSE, THE DATE OF THE OFFENSE, AND YOUR
REHABILITQATION SINCE THE CONVICTION(S). (A CONVICTION RECORD
WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT.)____________________

EMPLOYMENT DESIRED

POSITION(S) APPLIED FOR: ______________________________________________

DATE YOU CAN START: _________________________________________________

MONTH DAY YEAR

EMPLOYMENT AVAILABILITY: ______FULL TIME ______PART TIME

______7AM-3PM ______3PM-11PM ______11PM-7AM

WHAT ARE YOUR EMPLOYMENT INTENTIONS: ______LESS THAT 1 YEAR

______1-2 YEARS ______ INDEFINITELY

SCHOOL YEARS ATTENDED COURSE OF STUDY DEGREE/DIPLOMA

HIGH SCHOOL

COLLEGES

OTHER SCHOOLS

EMPLOYMENT HISTORY

LIST BELOW YOUR WORK EXPERIENCE (STARTING WITH YOUR PRESENT OR MOST
RECENT EMPLOYER) FOR THE LAST FIVE YEARS OR YOUR LAST THREE EMPLOYERS,
WHICHEVER WILL PROVIDE US WITH THE GREATEST INFORMATION ABOUT YOU.
USE THE REVERSE SIDE OF THE APPLICATION FORM IF YOU NEED ADDITIONAL
SPACE. PLEASE ACCOUNT FOR ALL PERIODS OF UNEMPLOYMENT IN THIS SECTION.

DATES OF NAME & ADDRESS NAME OF

EMPLOYMENT OF EMPLOYER SUPERVISOR JOB TITLE SALARY

FROM: _______ ___________________ _________________ __________ START________

TO: __________ ___________________ _________________ __________ FINNISH ______

TYPE OF BUSINESS ___________________________________________________________________

BRIEFLY DESCRIBE YOUR JOB DUTIES AND WORK EXPERIENCE: ________________________

REASON FOR LEAVING

________________________

DATES OF NAME & ADDRESS NAME OF

EMPLOYMENT OF EMPLOYER SUPERVISOR JOB TITLE SALARY

FROM: _______ ___________________ _________________ __________ START________

TO: __________ ___________________ _________________ __________ FINNISH ______

TYPE OF BUSINESS ________________________________________

BRIEFLY DESCRIBE YOUR JOB DUTIES AND WORK EXPERIENCE:

_____________________________________________________

REASON FOR LEAVING

_____________________________________________________

DATES OF NAME & ADDRESS NAME OF

EMPLOYMENT OF EMPLOYER SUPERVISOR JOB TITLE SALARY

FROM: _______ ___________________ _________________ __________ START________

TO: __________ ___________________ _________________ __________ FINNISH ______

TYPE OF BUSINESS ___________________________________________________________________

BRIEFLY DESCRIBE YOUR JOB DUTIES AND WORK EXPERIENCE:

___________________________________________________________________________________

REASON FOR LEAVING

____________________________________________________________________________________

**MAY WE SPEAK TO YOUR PRESENT EMPLOYER AT THIS TIME?

YES ______ NO ______

APPLICANT’S STATEMENT

I understand that if employed by Senior Monongalians, Inc.(SMI), I will be an employee at-will, which
means that I can voluntarily end my employment or be terminated at any time for any reason or no
reason at all. No statement whether written or oral, by any SMI representative other than a written
statement signed by the Executive Director may vary the foregoing. I give SMI permission to contact
all or any of my previous employers and references and authorize them to provide all information
requested of the by the SMI. After a tentative offer of employment has been made, if requested
by the SMI, I agree to take a job-related medical examination at no personal expense and authorize
the examining physician to disclose the findings to SMI. I understand that any offer of employment is
conditioned upon receipt of satisfactory references and satisfactory completion of such job-related
medical examination.

I have provided truthful and complete responses to all inquiries in the application and understand
that the discovery of any falsification or omission constitutes a ground for immediate dismissal.
If employed, I will abide by SMI’s rule and regulations, which understand are subject to change by SMI.

_____________________ _____________________________________

DATE APPLICANT’S SIGNATURE

PROFESSIONAL AND CHARACTER REFERENCES (OTHER THAN RELATIVES)

NAME ADDRESS PHONE NUMBER

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION.

APPLICANT’S SIGNATURE 

READ BEFORE SIGNING

I understand that Senior Monongalians, Inc. (SMI) insists that all of its employees by able to perform the
essential functions of their employment as well as possess the character, integrity and general reputation
for honesty that SMI would itself represent in its dealings with customers, suppliers and employees,
among others. Accordingly, SMI insists on complete honesty.

I, therefore, authorize SMI to make whatever inquiries it deems appropriate to verify any information given in
my application and/or determine my qualifications and ability to perform the hob for which I am applying.
I understand that my consideration for employment is contingent upon the results of this background/reference
investigation, including verification of previous assignments, education, military and criminal/law records;
authentication of the truth of all statements made in this application; personal and professional reference
checks, including inquiries into my character, work performance, general reputation and work habits;
and if necessary, to secure a credit report, investigative and otherwise concerning my credit worthiness
and other information permitted by state/federal law. I EXPRESSLY HEREBY GIVE MY CONSENT
FOR ALL CONTACTED PERSONS TO PROVIDE INFORMATION CONCERNING THIS
APPLICATION AND I RELEASE EACH SUCH PERSON FROM LIABILITY FOR PROVIDING
INFORMATION TO SENIOR MONONGALIANS, INC.

I hereby certify that the information contained in this application is correct to the best of my knowledge
and I understand that falsification of this application in any detail, including misrepresentation or omission
of facts, is grounds for disqualification from further consideration, or for dismissal from employment at a
later date. Furthermore I agree to conform to the rules and regulations of SMI and I UNDERSTAND
THAT, IF HIRED, MY EMPLOYMENT WILL BE FOR NO DEFINITE PERIOD OF TIME,
THAT I WILL BE AN EMPLOYEE AT-WILL, THAT I WILL BE FREE TO LEAVE
EMPLOYMENT WITH SMI AT ANY TIME AND FOR ANY REASON AND THAT SMI
MAY TERMINATE MYEMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE
AND WITH OR WITHOUT NOTICE. IUNDERSTAND THAT NOTHING IN ANY OF SMI’S
WRITTEN POLICIES, HANDBOOKS, OR OTHER DOCUMENTS SHOULD BY
CONTRACTUAL OBLIGATIONS ON THE PART OF SMI. FURTHERMORE, I
UNDERSTAND THAT NO ONE AT SMI IS AUTHORIZED TO MAKE ANY
CONTRACT RELATIN TO MY EMPLOYMENT UNLESS THE CONTRACT IS
SET IN WRITING AND IS SIGNED BY THE EXECUTIVE DIRECTOR OF SENIOR
MONONGALINS, INC.

_____________________________________________ __________________

Signature of Applicant Date