Employment ApplicationBSLNew2020-06-18T15:01:21-08:00 Project Description Please Complete our Online Application Please enable JavaScript in your browser to complete this form. - Step 1 of 6Main InformationDate of Application *Name *FirstLastEmail *EmailConfirm EmailSocial Security NoPhone *Present Address *Address Line 1Address Line 2CityAlaskaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextInformationAre you authorized to work in the U.S.?Business TelephoneCell TelephoneAre you authorized to work in the U.S.?YesNoAlient Registration Number/USCIS NumberCan you substantiate proof of identity and work authorization within 30 days of employment? *Yes PLEASE NOTE: This application form was designed for use by persons applying for various types of positions-clerical, professional, technical, and administrative. Please answer these questions to the best of your ability. You may answer "Not applicable". Position for which you are applying:Are you at least 18 years of age? *YesNoDo you wish to workFull-timePart-timeIf part-time, specify hours and days:Availability *WeekdaysWeekendsOvertimeDaysEveningNightsYour minimum hourly wage requirements:Date available for work: *Are you subject to non-competition or nondisclosure agreement or any other type of agreement with a former employer that might limit your right to work for us? If Yes, please explain:Drivers License #Expiration DateHas your driver's license in any state ever been surrendered, denied, suspended, revoked, restricted or investigated? *YesNoIf yes, please explainWere you in the U.S. Armed Forces? *YesNoIf yes, what branch?Dates of duty:Rank at Separation?Typing speedwords per minuteBusiness machines you can operateOther skillsProfessional License Type(Type, No., Expiration Date)Professional License IssuedAlaskaWashingtonMontanaOtherHas your license in any state ever been surrendered, denied, suspended, revoked, restricted, investigated or been placed on probation? YesNoIf yes, please explainHave you ever had any claims, judgments or settlements made against you in a professional liability case at any time during your professional practice? *YesNoIf yes, please explainHow did you hear about us? *WebsiteFriend/Colleague/Relative/Word of MouthSocial Media (Facebook, IG, etc...)OtherNextEducation InformationHIGH SCHOOL EDUCATIONPrint Name, Number and Street, City, State and Zip Code for each School ListingNo of years completedDegree of CertificateSubjects StudiedCOLLEGE/UNIVERSITYPrint Name, Number and Street, City, State and Zip Code for each School ListingNo of years completedDegree of CertificateSubjects Studied TRADE OR BUSINESS SCHOOLPrint Name, Number and Street, City, State and Zip Code for each School ListingNo of years completedDegree of CertificateSubjects StudiedNIGHT OR CORRESPONDENCE COURSESPrint Name, Number and Street, City, State and Zip Code for each School ListingNo of years completedDegree of CertificateSubjects Studied OTHERPrint Name, Number and Street, City, State and Zip Code for each School ListingNo of years completedDegree of CertificateSubjects Studied In the following spaces, give a complete record of your employment. Begin with your most recent employment and work back. Use the "Additional information" section or upload a separate sheet to list additional employers if you have had more than 3 former employers. NextEmployment InformationEMPLOYER NAMEEmployed From (month/year)Employed To(month/year)AddressStarting PositionLast PositionOther Position HeldStarting SalaryFinal SalarySupervisorReason for Leaving (Reason required why you resigned or terminated)EMPLOYER NAMEEmployed From (month/year)Employed To(month/year)AddressStarting PositionLast PositionOther Position HeldStarting SalaryFinal SalarySupervisorEMPLOYER NAMEEmployed From(month/year)Employed To(month/year)AddressStarting PositionLast PositionStarting Salary Final SalarySupervisorReason for Leaving (Reason required why you resigned or terminated)EMPLOYER NAMEEmployed From (month/year)Employed To(month/year)AddressStarting PositionLast PositionOther Position HeldStarting SalaryFinal SalarySupervisorReason for Leaving (Reason required why you resigned or terminated)Employed From(month/year)Employed To(month/year)AddressStarting PositionLast PositionOther Position Held Starting SalaryFinal SalarySupervisorReason for Leaving (Reason required why you resigned or terminated)NextAdditional InformationDo you currently suffer from any illness, injury, health condition (physical or mental) or contagious disease which would impair your current ability to safely carry out the responsibilities of the position for which you are applying? *YesNoIf yes, please explain:Except for vacations and holidays, how many work days were you absent during the curent calendar year? 0-5 days5-10 days10-15 days15-20 days21+ daysDuring the prior calendar year? 0-5 days5-10 days10-15 days15-20 days21+ daysPlease explain total absences over 5 days for each year:Did you receive any verbal warnings, written warnings or other disciplinary action concerning your performance of your job responsibilities at any of your previous jobs? *YesNoIf yes, please explain:Have you ever been unemployed at any time during the past 10 years? *YesNoIf yes, please state the date(s) and he reason(s) for your unemploymentHave you previously applied for employment here? *YesNoIf yes, whenHave you previously been employed by this property, or any of its affilated properties? *YesNoIf yes, when and which properties?Are any of your relatives or friends currently employed at Baxter or have in the past? If yes, please list name(s).Do you expect to also work elsewhere (full or part time) if employed here? *YesNoIf yes, please explainIn order to permit a check of your work and education records, please indicate any other names you have used in the past and relevant date(s)Person to Notify in Case of EmergencyName *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Upload Your Resume or Additional Employment Sheet Click or drag a file to this area to upload. NextApplication Agreement(Please read the following statements carefully before signing)I hereby affirm that the information provided on this application form (and accompanying resume, if any) is true and complete to the best of my knowledge and agree to advice the General Manager of this property in writing, of any change or addition to any information contained in this application. I agree that false information or the omission of information from this Application (including leaving blanks on this Application or my failure to correct or add to the information changes during the course of my employment). I authorize the investigation of my past employment and other qualifications of employment as deemed appropriate and agree to cooperate in such investigation. I agree to release, indemnify and hold harmless the Company from any and all liability in connection with its conducting such investigation as it deems appropriate and the use of the information received from third parties. I further agree to promptly advise the General Manager of this property in writing, of any mental or physical condition, illness or contagious disease or condition that may cause me to present a risk of harm to the residents or staff of the property. I consent to submit to such examinations and other health assessments requested by Baxter Senior Living. to determine my continuing qualifications to perform the essential responsibilities of any position I may have to be considered for by Baxter Senior Living.. I also agree to the release of copies of all health information requested by Baxter Senior Living. which is or may be related to my qualifications to work. I understand that if I am hired, my employment with Baxter Senior Living. may be terminated, with or without case, at any time at the discretion of either Company or myself. I understand that, if I am accepted for employment with Baxter Senior Living., the Company reserves the right to change my job responsibilities, wages, benefits and any other term or condition of my employment with Baxter Senior Living. at any time to meet the needs of Baxter Senior Living. I understand and agree that, at the time my voluntary or involuntary termination from employment with Baxter Senior Living, I am entitled to the wages I earned as of the last day I worked for Baxter Senior Living. I hereby agree that any amounts I owe to Baxter Senior Living at that time may be set off and applied against the wages owed to me at the time of termination. I further understand and agree that this is an application for employment and that no employment is being offered by this application.SignatureDate / TimeDateTimeEQUAL OPPORTUNITY EMPLOYERPhoneSubmit