Employee Application

EVENGLOW LODGE POLICIES ON EMPLOYMENT

STATEMENT ON EQUAL EMPLOYMENT OPPORTUNTIY

Evenglow is an Equal Opportunity Employer and is committed to maintaining a workplace free from discrimination on the basis of race, color, sex, religion, national origin, age, disability, or any other category or characteristic protected by law. Equal employment opportunity will be extended to all persons in all aspects of the employer/employee relationship, including recruitment, hiring, compensation, benefits, training, promotion, transfer, discipline, layoff, termination and social or recreational activities.

STATEMENT ON AT-WILL EMPLOYMENT

It is the policy of Evenglow that all employees who do not have a separate, individual written employment contract and/or agreement with Evenglow Lodge for a specific, fixed term of employment are employed at the will of Evenglow. Employment at Evenglow Lodge may be terminated with our without cause, and with our without advance notice any time by the employee or by Evenglow Lodge. Nothing in this application, or in any other document or general policy statement from Evenglow Lodge, should be construed as limiting the right of either the employee or Evenglow Lodge to terminate the employment relationship. In addition, Evenglow Lodge reserves the right to alter or change job responsibilities, promote, demote, reassign or transfer job positions, or assign additional job responsibilities at its sole discretion at any time.

I understand that nothing contained in this application or conveyed to me during any interview which may be granted is intended to create an employment contract, implied or explicit between me and Evenglow.

STATEMENT ON CERTAIN CRIMINAL CONVICTIONS

Evenglow finds that it is in the public interest to protect the most vulnerable and disabled citizens from possible harm through a criminal background check of all Evenglow employees.

Evenglow will not knowingly hire or employ any individual if that person has been convicted of committing one or more of the offenses listed in the Illinois Health Care Workers Background Check Act and associated regulations. A list of these offenses may be obtained from the Human Resources office.

STATEMENT ON INFORMATION PROVIDED FOR EMPLOYMENT CONSIDERATION

Any information provided to Evenglow for employment consideration purposes, including this application, resume or other written documents as well as verbal statements, must be true and correct to the best of the applicant’s knowledge. Any misrepresentation, falsification, or material omission by an applicant may result in Evenglow excluding an applicant from further consideration for employment, or, if hired, termination of employment.

POST-OFFER DRUG SCREENING

Employment with Evenglow is contingent upon successful completion of a post-offer drug screen prior to the first day of employment. Failure to pass the post-offer drug screen may result in withdrawal of the employment offer.

POST-OFFER PHYSICAL

Employment with Evenglow is contingent upon successful completion of a post-offer physical conducted by Evenglow’s physicians, prior to the first day of work. A pre-work screen is also required for all Certified Nursing Assistants, Universal Care Givers, Registered Nurses and Licensed Practical Nurses.

ELIGIBILITY TO WORK IN THE UNITED STATES

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire. Applicants for employment must be currently authorized to work in the United States on a fulltime basis.

Please answer the following questions:

Are you authorized to work lawfully in the United States for Evenglow Lodge?
YesNo
Will you now or in the future require sponsorship for employment visa status (e.g., H-IB visa status)?
YesNo
I have read and understand the policies, statements, and questions provided as part of Evenglow’s application process.

AUTHORIZATION FOR REFERENCE WAIVER/RELEASE OF CLAIMS

I have applied to EVENGLOW LODGE for employment consideration. In order that EVENGLOW LODGE can better evaluate my qualifications, I wish that EVENGLOW LODGE be fully advised of my performance and record with you.

I give EVENGLOW LODGE the right to investigate all references and past employment to secure information about me in order to arrive at a hiring decision. I also authorize all persons, institutions, organizations and companies to furnish any and all information sought, and I waive any legal requirements to provide notice to me regarding reports, records or information given or received in accordance with this authorization.

I hereby release and hold harmless EVENGLOW LODGE, its agents and employees from any claim of liability I may have against it and/or them for decisions, even if adverse, arising out of information received in response to the above Authorization for Reference.

I further hereby authorize any person or entity to which this Authorization for Reference is presented to and release any information required therein to EVENGLOW LODGE, its agents or employees.

I further agree to hold harmless any person or entity from any claims of liability I may have against such person/entity for the release of such information, and waive and release any such claims.

I hereby acknowledge that I have read and understand each of the above statements.
Attach Cover Letter

PERSONAL INFORMATION

Last Name
Street Address
City
First Name
Email
State
Middle Initial
How Long at This Address
Zip Code
Home Phone
Alternate Phone

POSITION DESIRED AND AVAILABILITY

Position Desired
Are You at Least 18 Years OldYesNo
Availability (You may select more than one)
If NOT, please state your age
Pay Rate Desired

PREVIOUS EVENGLOW EXPERIENCE

Have You Applied at Evenglow BeforeYesNo
Have You Worked at Evenglow BeforeYesNo
Do You Have Relatives Working at EvenglowYesNo
If Yes, When
If Yes, When
If Yes, List Name and Relationship
What Department
What Department
What Position
What Position

EMPLOYMENT PREFERENCES

Work Shift Availability (You may select more than one)
Work Status Availability (You may select more than one)
Days of the Week Availability (You may select more than one)

EMPLOYMENT HISTORY

Employer 1 Details

Employer Name
Starting Date of Employment
Wages Starting
Type of Business
Ending Date of Employment
Wages Last
Phone Number
May we Contact?YesNo
Still EmployedYesNo
Address
Supervisor's Name/Title
State Last Job Title and Describe Your Work
Reason For Leaving

Employer 2 Details

Employer Name
Starting Date of Employment
Wages Starting
Type of Business
Ending Date of Employment
Wages Last
Phone Number
May we Contact?YesNo
Still EmployedYesNo
Address
Supervisor's Name/Title
State Last Job Title and Describe Your Work
Reason For Leaving

Employer 3 Details

Employer Name
Starting Date of Employment
Wages Starting
Type of Business
Ending Date of Employment
Wages Last
Phone Number
May we Contact?YesNo
Still EmployedYesNo
Address
Supervisor's Name/Title
State Last Job Title and Describe Your Work
Reason For Leaving

List any relatives or friends working for Evenglow

Name
Name
Name
Name
Relationship
Relationship
Relationship
Relationship

EDUCATIONAL BACKGROUND

School Name and Location
School Name and Location
School Name and Location
School Name and Location
Number of Years
Number of Years
Number of Years
Number of Years
Certificate Earned
Certificate Earned
Certificate Earned
Certificate Earned

LICENSE AND CERTIFICATION INFORMATION

License Certification
License Certification
License Certification
License Certification
Licenses Applicable
Licenses Applicable
Licenses Applicable
Licenses Applicable
Date Issued
Date Issued
Date Issued
Date Issued
Expiration Date
Expiration Date
Expiration Date
Expiration Date
License of certification ever revoked?YesNo
Disciplinary action initiated?YesNo
If so, outcome of disciplinary action initiated

REFERENCES

Name
Name
Name
Name
Title
Title
Title
Title
Business/Profession
Business/Profession
Business/Profession
Business/Profession
Phone Number
Phone Number
Phone Number
Phone Number
Years Known
Years Known
Years Known
Years Known

BACKGROUND

Will we be able to verify your legal rights to work in the U.S. by providing a birth certificate, proof of U.S. Citizenship, or by some other means?YesNo
If you are under the age of 18, are you able to furnish a work permit?YesNo

Evenglow will not knowingly hire or employ any individual if that person has been convicted of committing one or more of the offenses listed in the Illinois Health Care Workers Background Check Act and associated regulations. This list is extensive and includes crimes such as: assault, battery, theft, forgery, reckless endangerment of a child, abuse or criminal neglect on an elderly person.

Have you been convicted of a crime that could disqualify you from working in a Long Term Care facility??YesNo