Personal Information
First Name:
Middle Name:
Last Name:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Current Address
Street:
City:
State:
Zip Code:
Employment Information
For which position are you apply:
Number of hours per week you would like to work:
Date You Can Start:
(DD/MM/YYYY)
At which Willow Brook location would you be most interested in working?:
When would you prefer to work?
 Daytime
 Evenings
 Nights
Please list specific times you would not be available:
Please answer all of the following questions.
1.
Are you legally eligible to work for our company in the United States?
If hired, you are required to submit proof of your eligibility to work in the U.S.A.
2.
Are you over the age of 18?
If no, hire is subject to verification that you are of minimum legal age.
3.
Have you been known by another name?
 
If yes, what?
 
4.
Have you applied at Willow Brook before?
 
If yes, when?
 
5.
Do you know anyone who is or was employed by Willow Brook?
 
If yes, who?
 
6.
Have you worked for Willow Brook before?
 
If yes, please provide dates and locations.
 
7.
Can you perform the essential functions of the job for which you are applying with or without reasonable accomodations?
8.
Is there any work you will not perform?
 
If yes, please explain.
 
9.
If hired at Willow Brook, are you prepared to provide your medical history and take a physical exam, including a drug screening?
10.
Are you currently debarred, excluded, or deemed ineligible for participation in a federally funded health care program or to receive federal funds?
11.
Have you ever been convicted of a crime?
(Convictions will not necessarily disqualify an applicant for employment)
 
If yes, please explain.
 
12.
How did you hear about Willow Brook's employment opportunities?
 
13.
What qualifications, skills, experience or interests could you bring to Willow Brook?
 
14.
Why would you like to work for Willow Brook?
 
15.
Are you currently employed?
 
If yes, may we contact your present employer?
 
16.
Have you ever been discharged or asked to resign from a job?
 
If yes, please explain.
 
16.
List all periods during which you were unemployed:
 
17.
How did you spend this time?
 
Employer (begin with most recent)
May we contact this employer?
Employer:
Address:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Starting Pay:
Pay Upon Leaving:
Supervisor:
Duties (include skills that you could apply at Willow Brook):
Reason For Leaving:
Prior Employer (1)
May we contact this employer?
Employer:
Address:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Starting Pay:
Pay Upon Leaving:
Supervisor:
Duties (include skills that you could apply at Willow Brook):
Reason For Leaving:
Prior Employer (2)
May we contact this employer?
Employer:
Address:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Starting Pay:
Pay Upon Leaving:
Supervisor:
Duties (include skills that you could apply at Willow Brook):
Reason For Leaving:
Prior Employer (3)
May we contact this employer?
Employer:
Address:
City:
State:
Zip Code:
Phone:
Position Held:
From (m/yyyy):
To (m/yyyy):
Starting Pay:
Pay Upon Leaving:
Supervisor:
Duties (include skills that you could apply at Willow Brook):
Reason For Leaving:
High School
School:
City:
State:
Years completed:
Diploma:
Undergraduate School
School:
City:
State:
Years completed:
Diploma:
Deg/Cert/Dip:
Area of Study:
Graduate School
School:
City:
State
Years completed:
Diploma:
Deg/Cert/Dip:
Area of Study:
Other School
School:
City:
State:
Diploma:
Deg/Cert/Dip:
Area of Study:
Professional, Educational or Civic Organization Membership
(You may exclude those which would reveal gender, race, religion, national origin, age, ancestry, disability or any other protected status):
 
Additional Qualifications or Information
(Please provide any information that you feel may be helpful in considering your application):
 
Professional Reference (1) (List only those who can verify your work history, performance or skills. Please do not list family members or friends.)  
Name:
Address:
Telephone:
Relationship:
Professional Reference (2)
Name:
Address:
Telephone:
Relationship:
Professional Reference (3)
Name:
Address:
Telephone:
Relationship:
Applicant's Certification Agreement
1.
The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits, and participation in union activities. The laws of most states and many localities also prohibit some or all of the above types of discrimination as well as some additional types including, but not limited to, discrimination based upon ancestry, marital status, parental status, sexual orientation, or source of income. The Fair Credit Reporting Act imposes restrictions with respect to information obtained from a consumer reporting agency, including but not limited to information regarding credit data, personal character, general reputation, and mode of living. This list, however, is not exhaustive of the grounds on which discrimination is prohibited.
2.
By my signature below, I promise that the information provided in this employment application (and accompanying resume or documentation, if any) is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from further consideration for employment, and may lead to my dismissal from employment, if discovered at a later date. I agree to notify Willow Brook if I should be convicted of a felony, or any crime involving dishonesty, theft, breach of trust, controlled substances, sexual misconduct, abuse, or violence, while my job is pending, or during my period of employment if hired.
3.
I authorize any person, school, current employer, past employer(s), organizations named in this application (and accompanying resume, if any) and federal, state, county, and local agencies to provide Willow Brook with any information and opinions requested by Willow Brook in connection with any application, and I release such persons and organizations from any legal liability in making such statements.
4.
I understand that this application does not create a contract of employment. I understand that, if hired, I am obliged to comply with any and all current and subsequently adopted Willow Brook policies. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time for any reason, with or without notice.
5.
As part of my application for employment, I may be asked to sign a release of information authorization. This is to allow Willow Brook to verify my references and, in Willow Brook's discretion, to perform other background investigations to determine my qualification for employment. Through a separate agency, Willow Brook may choose to investigate my academic credentials, prior employment, personal/professional references, credit record, motor vehicle record, and/or criminal record. I will be provided with a separate authorization and release form for this purpose.
 
Resume
Upload your resume (optional):
Signature
Type Name in Signature Box:
Today's Date: 09/21/2014