Employment Application

Step 1: Name and Address

Pacifica Companies is an equal opportunity employer and makes employment decisions on the basis of merit. We want to have the best available persons in every job. Pacifica Senior Living’s Policy prohibits unlawful discrimination based on race, color, sex, religion, national origin, ancestry, a physical or mental impairment that substantially limits one or more major life activities, marital status, age or any other consideration made lawful by federal or local laws. All such discrimination is unlawful.

First Name: *

Middle Name: *

Last Name: *

Email Address: *

Primary Phone: *

Address:

City:

State / Province:

Zip Code:

Who Referred You:

Salary Expectations:

Per

Step 2: Job Title / Position(s) Applying For

Select a Job Title / Position: *

Select a Community: *

Step 3: Work Schedule

Employment Type: *

Available Start Date: *

Preferred Shift: *

Hours / Days available to work: *

Hours / Days NOT available to work:

Step 4: Employment History

Company Name: *

City: *

State / Province: *

Employment Start: *

Employment Ending: *

Position: *

Supervisor: *

Reason for Leaving: *

Step 5: Other Information

Do you have a valid drivers license: *

Have you been previously employed by Pacifica Senior Living: *

If "Yes" - which location(s):

Dates of employment:

Step 6: Education History

Step 8: Certifications / Licenses

Step 9: References

Step 10: Eligibility / Conditions of Employment

Are you legally eligible to work in the U.S. *

Can you perform all essential job functions with or without accommodation: *

CONDITIONS OF EMPLOYMENT: *

Sets high standards for its employees. Compliance with these standards is a Condition of Employment. You need to carefully consider these requirements before accepting a position with us. As an employee, you will be expected to comply in full with the following conditions and other conditions of employment set out in Pacifica Senior Living.

CUSTOMER SERVICE: *

Treat residents with an exceptionally friendly attitude at all times and under all circumstances.

ATTENDANCE/PUNCTUALITY: *

Always report to work when scheduled and on time.
Call the Community before your scheduled shift when unable to report to work as scheduled.

PERSONAL APPEARANCE: *

Maintain a business-like, professional appearance (dress and grooming).
Wera your community name badge at all times.

Will you comply with all the requirements as listed: *

If "No", please explain: *

ACKNOWLEDGEMENT AND AGREEMENTS

ALL APPLICANTS - Please read the following and address any questions to the Pacifica Senior Living Representative before signing below:

I hereby affirm my answers to the foregoing questions are true and correct. I understand that misrepresentation of the facts will result in immediate dismissal. This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and as applicable, information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I hereby authorize these persons, companies, organizations or corporations to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or record.

I authorize the Company to release to any person, firm, entity or organization with which I may seek employment in the future, any truthful information concerning my work experience with the Company. I hereby release and hold the Company harmless from any claim for releasing any truthful information within its knowledge and/or records.

I understand that satisfactory reports are a condition of my employment with Pacifica Senior Living, LLC. I further understand that my employment with Pacifica Senior Living, LLC will be terminated if management determines that said reports are unsatisfactory. I also acknowledge that from time to time Pacifica Senior Living, LLC may be required to submit certain information with regard to my employment or application for employment. I hereby release the Company, its agents, assigns and subsidiaries from any liability resulting from submitting such information.

I understand that my employment is at will and that I can be terminated at any time, with or without notice and with or without any reason. I understand that if I am employed, employment is not for a stated period. Either Pacifica Senior Living, LLC or I may discontinue the employment relationship at any time without cause or notice. Only the President of Pacifica Senior Living, LLC has the authority to enter into an agreement contrary to the foregoing, and then such agreement must be in writing and signed by President. No other practice, written or oral policy or statement by anyone, including for managers or any other management personnel can alter this employment relationship.

I acknowledge that Pacifica Senior Living, LLC may request either prior to and/or after employment that I undergo drug testing and may request, after an offer has been made, a medical exam. I consent and agree to any such exam, if required, now or in the future. I understand that when pre-employment drug testing is required, a satisfactory result is a condition of employment with Pacifica Senior Living, LLC.

I hereby certify that all statements and answers made on this Employment Application are complete and true. I understand that if subsequent to employment any of such statements and/or answers are found to be false or that information is omitted, such false statements or omissions will result in termination of my employment.

If Pacifica Companies deems it necessary to obtain a criminal record check or driver’s record on me, by signing this application I hereby authorize Pacifica Companies to request my criminal history information and driver’s record.

This application is current only for thirty (30) days, at the conclusion of which time, if you have not heard from us and still wish to be considered for employment, it will be necessary for you to fill out a new application.

* I confirm that I have read all of the above requirements and agree to comply with them fully.