Main: 512-454-4711

Marketing: 512-454-4643

Health Care Center &
CNA Training: 512-454-2140

Job Line: 512-600-7315

Fax: 512-371-7308

Email: info@wmanor.org

Online Application For Employment

Please complete all sections of this form to the best of your ability. Many sections contain required fields (*) that must be completed in order to submit the application for processing.

Westminster Manor is an Equal Opportunity Employer.

All qualified applicants will receive consideration without discrimination because of race, color, religion, sex, age, disability, national origin or veteran status.

In order to protect your privacy and to provide the highest level of security possible, all information provided below will be encrypted when your online application is submitted. This site has been issued a QuickSSL™ certificate which means you can rest assured that communications between your browser and this site's web servers are private and secure.

Applicant Information

Last Name *

First Name *

Middle Name

Are you 18 years or older? *

Yes No

Street Address *

City *

State *

Zip Code *

Telephone Number *

Alternate Telephone Number

Are you legally eligible for employment in the U.S.? *

Yes No

Social Security Number *

Position and Eligibility

Position you are applying for *

Desired Shift (if applicable)

Date Available *

Minimum Salary Desired *

Name of first relative employed by us (if applicable)

First relative's Location/Department

First relative's Position

First relative's relationship to you

Name of second relative employed by us (if applicable)

Second relative's Location/Department

Second relative's Position

Second relative's relationship to you

Have you applied for a position with us before? *

Yes No

If yes, please give date(s) and position(s) applied for

Have you ever been employed by us? *

Yes No

If yes, please give date(s) and position(s) held

Education

High School

Location

Did you graduate?

Yes No

Major Subject

College

Location

Did you graduate?

Yes No

Major Subject

Trade School

Location

Did you graduate?

Yes No

Major Subject

Employment History

List employment starting with your most recent job during the last 10 years. Account for any time period that you were unemployed by stating the nature of your activities.

May we contact your current employer? *

Yes No

Current Employer

Telephone Number

Street Address

City

State

Zip Code

From

Position

Supervisor's Name

Starting Salary

Ending Salary

Duties

Reason for leaving

Past Employer One

Telephone Number

Street Address

City

State

Zip Code

From

Position

Supervisor's Name

Starting Salary

Ending Salary

Duties

Reason for leaving

Past Employer Two

Telephone Number

Street Address

City

State

Zip Code

From

Position

Supervisor's Name

Starting Salary

Ending Salary

Duties

Reason for leaving

Past Employer Three

Telephone Number

Street Address

City

State

Zip Code

From

Position

Supervisor's Name

Starting Salary

Ending Salary

Duties

Reason for leaving

Additional Experience

List any professional groups, trade groups, or other organizations you belong to that you consider relevant to your ability to perform the job(s) for which you are applying

List experience from your military service that would be relevant to the job(s) for which you are applying

References

List two (2) professional references and one (1) personal reference that we may contact immediately.

Professional Reference One *

Relationship to you *

How long have you known this person? *

Professional Reference Two *

Relationship to you *

How long have you known this person? *

Personal Reference *

Relationship to you *

How long have you known this person? *

Criminal History

Have you ever been convicted of a felony? *

Yes No

If yes, please explain

Job Description and Requirements

Have you been given a job description or had the requirements of the job explained to you? *

Yes No

Do you understand the requirements? *

Yes No

Can you perform the requirements of this job with or without reasonable accommodations? *

Yes No

If the job requires, do you have the appropriate valid driver's license? *

Yes No

Driver's License Number

Type

State of Issue

Terms of Application

Please read the following statements, and acknowledge that you understand the information presented by checking each corresponding box.

I UNDERSTAND:

- that completing this application does not constitute an offer of employment and that my application may be rejected for any reason. *

- that giving false or misleading information on this form or in an interview is grounds for denial or immediate termination of employment. *

- that I may be required to complete a medical history form and may be required to be examined by a medical professional designated by Westminster Manor. *

- that if I sustain any injury or illness in the employment of Westminster Manor, I agree that Westminster Manor shall be entitled to receive full and complete reports and records covering any medical or related exams, and I authorize the any and all such doctors, medical examiners, and hospitals to give to Westminster Manor full and complete reports and records covering such examinations, condition, care, and treatment related to or resulting from the alleged illness or injury. *

Release of Information

Please read the following statements, and acknowledge that you understand the information presented by entering your name and today's date in each corresponding field.

AUTHORIZATION TO RELEASE INFORMATION:

• If I am given a conditional offer of employment, I authorize Westminster Manor to make a complete investigation of me, including but not limited to: my past employment history, scholastic records, criminal records, abuse records, motor vehicle driving records, workers' compensation history and to rely on such information sources. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephone facsimile (FAX) or photographic copy shall be as valid as the original.

• By signing below, I certify that I have not been convicted of an offense that would preclude working in a nursing facility. I also certify that I am not excluded from participation in federal health care programs. Furthermore, I understand that I will be subject to a search of the OIG List of Excluded Individuals.

• I understand that the use of illegal drugs is prohibited during employment. If employment policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and/or during employment.

• I understand that this employment application and any other employee-related documents are not contracts of employment; and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee.

Applicant Signature (entering your name here will serve as an electronic signature) *

Date of Signature *

Westminster Manor

4100 Jackson Avenue, Austin, Texas 78731 Ph: 512-454-4711