Employment Application

Personal Information:

Are you 18 years or older?
Are you known to schools/references by another name? If yes, by what name?
Are you either a United States citizen or an alien who has the legal right to work in the job for which you are applying? (Upon acceptance of an offer of employment, official documentation verifying identity and authorization for employment must be produced prior to the start of employment.)
Have you ever been convicted (including a guilty plea) of a crime?
If yes, please describe in full

Employment Goals:

Type of Employment Desired:
Shift Desired
Are you willing to work Weekends?
Date you desire to begin work?
Are you presently employed?
May we contact your current employer?
Briefly state any special skills or qualifications you have which you feel are related to the position for which you are applying:
List Volunteer/Community Service positions which you feel are relevant to the position for which you are applying:


High School
Did you graduate or receive a GED?
If yes, select one
College or University


Have you ever worked in a home for the aged or other health care facility?
Why are you interested in working for Fellowship Community?
How did you learn about employment opportunities at Fellowship Community?

Employment History:(Please list PRESENT or LAST employer first)

Personal References:(Please do not include Relatives)

Inquiry Authorization:

I authorize investigation of all statements contained in this application, present employer and specifically authorize any personal or employment reference to provide information to Fellowship Community. I hereby affirm that all statements and answers made in this application are true and correct and that I have not knowingly failed to disclose any material fact regarding my former actions or employment. Any misrepresentation by me will be sufficient cause for cancellation of the application and/or for termination from Fellowship Community’s employment if I have been employed.

I agree to fill out and sign all papers required of a new employee and abide by Fellowship Community's rules of conduct and safety. I understand that my employment is contingent upon successfully passing a physical examination, drug and nicotine screening, criminal history background check, license/certificate verification, Office of the Inspector General investigation and meeting the state requirements when applicable. In addition, I understand my continued employment is at the will of Fellowship Community and that any other representation with respect to the term of guarantee of employment must be in writing and signed by the administrator of Fellowship Community in order to be effective. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause.

If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.

It is the policy of Fellowship Community to provide equal employment opportunities for all persons without regard to race, color, religion, sex, age, sexual orientation or national origin. This policy also applies to veterans and handicapped applicants. Fellowship Community is an equal opportunity employer.