Application For Employment

St. Anne's Retirement Community is an Equal Opportunity Employer. We consider applicants for all positions on the basis of qualifications and without regard to race, color, religion, sex, national origin, age, marital status, veteran status, disability, sexual orientation and any other legally protected status.

Click Here for printable PDF version of this application.

Personal Information
Name: (Last, First, Middle)
Present Address:
City:
State:      Zip:
Phone:
Have you lived in the state of Pennsylvania for the past two years?: Yes No
E-mail:

Were you ever employed here? Yes No
If yes, when and why did you leave?

Are you 18 years or older?       Yes No

Are you legally eligible for employment in the United States? Yes No
(If offered employment you will be required to provide documentation to verify eligibility.)

How Did You Learn About Us?: Newspaper Ad   Job Fair Other
Referred by:

Have you ever been convicted of a felony or misdemeanor? Yes No
If so, explain:
(Employment will be considered to the extent that convictions are not on the prohibited list for hire in Long term Care Facilities.)

Have you ever been involved in or reported for abusing or neglecting a client?
Yes No

Check which applies:
I do I do not   have a history of or conviction for violent crimes.
I was I was not   dismissed from employment due to abuse of clients, residents or fellow employees.
(Criminal background checks are required and completed for long term care and Personal Care applicants)

Employment Desired
Position Applying For:
Job Type Requesting: Part Time   Full Time
Shift:

Education
High School
School:        City / State:  
Number of years completed:     1  2  3  4
Graduated?: Yes   No

College
School:        City / State:  
Number of years completed:     1  2  3  4
Graduated?: Yes   No
Major:       Degree(s) Earned:

Vocational/ Technical School
Certificate Obtained:   

Please describe additional skills, training or ability you would like to have us consider in evaluating your qualifications.

U. S. Military Service
Dates of Service:     From:     To:      Branch:
Rank & Principle Duties:   
Type of Discharge:   

Employment History
May we contact your employer?: Yes   No 
If any employment was under a different name (i.e. maiden name) indicate here:

List names of employers in consecutive order with present or last employer first, including Military Service.

Employer:     Position:     
Address:     Telephone: 
Employed: From:    Employed: To:    Pay Start:     Pay End: 
Reason for Leaving:

Employer:     Position:     
Address:     Telephone: 
Employed: From:    Employed: To:    Pay Start:     Pay End: 
Reason for Leaving:

Employer:     Position:     
Address:     Telephone: 
Employed: From:    Employed: To:    Pay Start:     Pay End: 
Reason for Leaving:

Personal Reference
Give the names of three people not related to you whom you have known for at least 2 years.

Name:     Address:     
Occupation:     Phone:  Years Known: 

Name:     Address:     
Occupation:     Phone:  Years Known: 

Name:     Address:     
Occupation:     Phone:  Years Known: 

Agreement

I have applied/accepted employment at St. Anne's Retirement Community. In doing so, I understand that St. Anne's Retirement Community has a special obligation to clients, residents and staff in respect to their personal property and safety. I hereby give St. Anne's Retirement Community the right to make a thorough investigation into my previous employment, education, references, character and I release from all liability all persons supplying such information. The investigation is not limited to the above and criminal checks both State and Federal can be required. I authorize all public officials or persons involved in reference for employment to furnish information necessary for employment at St. Anne's Retirement Community. Records obtained will be confidential.

I release, indemnify, and hold harmless St. Anne's Retirement Community from and against any and all liability that might result from making such an investigation. I also understand that any false statement, or misrepresentation made by me in this application shall constitute sufficient cause for discharge.

I understand that nothing contained in this employment application or granting an interview is intended to create an employment contract between St. Anne's Retirement Community and myself for either employment or for the granting of benefits.

No promise regarding employment has been made to me, and I understand that no such promise or guarantee is binding upon St. Anne's Retirement Community unless made in writing. Employment offers are contingent upon the successful completion of all of St. Anne's pre-employment requirements. If an employment relationship is established, I understand and agree that it is not for a definite period of time and that I have the right to terminate my employment at any time and that St. Anne's Retirement Community retains a similar right.

I understand that, if accepted for employment, it is necessary to abide by the rules and policies of St. Anne's Retirement Community and that I will be on a ninety-day (90) probation before being considered a regular employee.

I affirm that I have a genuine intent and no other purpose in applying for a job with St. Anne's Retirement Community.

I Agree I Do Not Agree



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3952 Columbia Avenue, Columbia, PA 17512-1715
Phone: (717)285-5443 - Contact Us