Online Job Application Form – Woodland Care Center – Independent and Assisted Living

Application For Employment

"*" indicates required fields

Step 1 of 2

50%

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Are you legally eligible to work in the US?*

Yes

Are you a veteran*

Yes

If selected for employment are you willing to submit to a background check?*

Yes

Position

Position you are applying for*

Available start date*

MM slash DD slash YYYY

Desired pay*

Employment desired*

Full time

Part time

Seasonal/Temporary

Education

School name (1)*

Location (1)*

Years attended (1)*

Degrees received (1)

Major (1)

School name (2)

Location (2)

Years attended (2)

Degrees received (2)

Major (2)

School name (3)

Location (3)

Years attended (3)

Degrees received (3)

Major (3)

School name (4)

Location (4)

Years attended (4)

Degrees received (4)

Major (4

References

We need two business/professional and one personal reference. Thank you.

Name of professional (1)*

Title (1)*

Company (1)*

Phone (1)*

Name of professional (2)

Title (2)

Company (2)

Phone (2)

Name of Personal Reference

Title (3)

Relationship

Phone (3)

Employment History

Starting with your most recent employment.

Employer (1)*

Job title*

Start date*

MM slash DD slash YYYY

End date*

MM slash DD slash YYYY

Work phone*

Starting pay rate*

Ending pay rate*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (2)

Job title

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Work phone

Starting pay rate

Ending pay rate

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (3)

Job title

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Work phone

Starting pay rate

Ending pay rate

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer (4)

Job title

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Work phone

Starting pay rate

Ending pay rate

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature Disclaimer

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my employment being terminated.

Name*

First Last

Date*

MM slash DD slash YYYY

Shift Availability

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Background Check Authorization

SECTION 2.

Background Check Instructions

6. Social Security Number

7. Date of birth*

MM slash DD slash YYYY

8. Email*

9. REQUIRED: ENTER YOUR NAME AS IT IS LISTED ON YOUR DRIVER'S LICENSE OR OTHER PHOTO ID: WRITE N/A IN THE BOX IF YOU DON'T HAVE A NAME TO ENTER.*

First Middle Last

10. REQUIRED: ENTER ALL OTHER FIRST, MIDDLE AND LAST NAMES YOU HAVE USED. LEAVE BLANK IF YOU DON'T HAVE A NAME TO ENTER.*

First Middle Last

11A. Have you been convicted of any crime? If yes, fill in the blanks below.*

Yes

Crime

Degree

State

State / Province / Region

Conviction date

MM slash DD slash YYYY

11B. Do you have charges (pending) against you for any crime? If yes, fill in the blanks below.*

Yes

Crime

Degree

State

State / Province / Region

12. Has a court or state agency ever issued you an order or other final notification stating that you have sexually abused physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult?*

Yes

13. Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a government agency was taking action against you for failing to care for children, juveniles, or vulnerable adults.*

Yes

14. Has a court ever entered any of the following against you for abuse, sexual abuse, neglect, abandonment, domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile or child?*

Yes

Permanent* vulnerable adult protection order / restraining order, either active or expired, under RXW 74.43.
Sexual assault protection order under RCW 7.90.
Permanent* civil anti-harassment protection order,either active or expired, under RCW 10.14.

15. REQUIRED: PRINT YOUR DRIVER'S LICENSE OR STATE IDENTIFICATION NUMBER (WRITE NONE IF NONE)*

REQUIRED: PRINT THE NAME OF THE SATE ON YOUR LICENSE OR ID*

First Last

16. REQUIRED: Have you lived in any state or country other than Washington State within the last three years (36 months)*

Yes

17. A. REQUIRED: ENTER YOUR MAILING ADDRESS WHERE WE CAN SEND YOU CONFIDENTIAL INFORMATION*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

B. REQUIRED: ENTER THE STREET ADDRESS WHERE YOU LIVE NOW (LEAVE BLANK IF YOUR STREET ADDRESS IS THE SAME AS YOUR MAILING ADDRESS)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

C. REQUIRED: GIVE THE DAYTIME AREA CODE AND TELEPHONE NUMBER WHERE YOU CAN BE REACHED*

I give DSHS permission to check my background with any governmental entity and law enforcement agency.
My background check result may include prior self-disclosure information and fingerprint results that are contained in the DSHS Background Check System and that this information will be reported as allowed by federal or state law.
If a final finding is identified, DSHS will report only my name and that a final finding was identified on the background check result.
DSHS will give my background check result to the persons or entities named in Section 1 and may release my background check results to other persons or entities when the law authorizes or requires DSHS to do so. Fingerprint rap sheets are provided if allowed by federal or state law.
The entity requesting this background check must submit this form to the Background Check Central Unit within the timeframe required by the DSHS oversight program.

Today's date*

MM slash DD slash YYYY

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