Careers – Fern Terrace – Owensboro, Ky.

Personal

Name*

First Middle Last

Permanent Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Do you have the legal right to live and work in the U.S.?*

Yes
No

Other name(s) under which you have been previously employed

Names of friends or relatives employed in this organization

Have you ever applied to this organization before?*

Yes
No

If Yes, give date and position applied for

Have you ever been employed by this organization before?*

Yes
No

If yes, list dates of employment

Have you ever been convicted of a felony?*

Yes
No

If yes, list dates, offenses, and disposition.

Convictions are not an automatic disqualification from employment.

Will you comply with the safety work and attendance policies of our organization?*

Yes
No

Employment Interests

Location(s) you are applying for*

Fern Terra Assisted Living (Owensboro)
DAVCO Personal Care Home (Owensboro)
Fern Terrace of Owensboro Personal Care Home
Fern Terrace of Mayfield Personal Care Home

Position(s) Desired or Area of Interest:*

Janitorial
Floor Technician
Medication Aid

Date Available*

Type of Employment You Are Seeking:*

Full Time
Part Time
Temporary

How were you referred to our organization?*

Name of Referral Source:

Education/U.S. Military Service

Where did you attend high school & college? (Click the + button to add a new row)*

School Name & Address	Major	Years Completed	GPA	Degree/Diploma

Are you taking any educational course(s) presently?*

Yes
No
I will be soon

If Yes or you will be soon, what and where?

Have you ever served in the U.S. Armed Services?

Yes
No

US Military Duties and special training

Rank held at discharge

References

List 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include relatives. (Click the + button to add a new row)

Name	Address	Occupation	Years Known

Employment History

Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.

Company Name (Most Recent)

Address

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

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Did you have another job before this one?*

Yes
No

Company Name (Second Most Recent)

Address

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

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Would you like to list another previous job?

Yes
No

Company Name (Third Most Recent)

Address

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

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Would you like to list a 4th job?

Yes
No

Company Name (Fourth Most Recent)

Address

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

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

I agree to a Drug Screening at the company's expense.*

Yes
No

I agree to a Criminal Background Check at the company's expense.*

Yes
No

Acknowledgement

I certify that the statements made on this application are true and correct to the best of my knowledge and belief and hereby grant permission to verify such answers. I understand that any false statement on this application may be considered as sufficient cause for rejection of this application, or for dismissal if such false statement is discovered subsequent to my employment. I further understand that a preemployment investigation will be performed to determine my suitability for employment and I authorize written access to any records concerning my education, employment, or criminal background. I understand that if any injury is made, all information as to it's nature and scope will be supplied upon request. If this application is considered favorably, I may have to pass a physical examination as condition of employment, and I agree to abide by and comply with all rules of this facility. I understand and agree that, if hired, my employment is for no defined period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.

Digital Signature:

Printing your First Name + Middle Initial + Last Name will act as your digital signature.

EOE Statement

We are an equal opportunity employer, federal law prohibits discrimination in employment practices because of race, color, religion, sex, age, national origin, or handicapped status. No question on this application is asked for the purpose of limiting or excluding any applicant's consideration for employment because of his or her race, color, religion, sex, age, national origin, or handicapped status.

Careers Join Our Team

Employment Application

Personal

Employment Interests

Education/U.S. Military Service

References

Employment History

Acknowledgement

Davco Homes Inc. Corporate Office

Fern Terra Assisted Living

Fern Terrace of Owensboro

DAVCO

Fern Terrace of Mayfield