* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you ever been convicted of a felony or a misdemeanor? (No applicant will be denied a position because of a conviction for any offense which is not related to the circumstances of the job(s) sought.):

Yes   No

If Yes, please list all convictions, felonies and/or misdemeanors other than minor traffic violations and include dates, offenses and charges.:

* Have you ever been found guilty or plead guilty to abuse, neglect or mistreatment of a person?:

Yes   No

If yes, please explain:

* Have you ever been excluded or prohibited from being paid with federal programs or money?:

Yes   No

.

If yes, please explain:

* Have you ever worked for Cross Keys Village - The Brethren Home Community before?:

Yes   No

If Yes, please provide details (Where/When/Job Title and indicate other names worked under):

* How did you find out about this position?:

Indeed   Career Builder   Glassdoor   Juju   Facebook   LinkedIn   The Merchandiser   York Community Courier   Billboard/Sign   Agency   Job Fair Referral   Current Team Member Referral   Other

If referred by a current CKV Team Member, please list their name(s) here:

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time Seasonal On Call Weekends Only

* Shift desired:

Day    Evening    Nights

* Are you currently employed?:

Yes   No

If presently employed, why are you considering leaving?:

Name	Relationship	Phone Number	Email
*	*	*
*	*	*
*	*	*

I understand that any falsification or omission of information will be sufficient cause for the disregarding of this application or termination of my employment.

I agree that an investigation may be made, and I hereby authorize Cross Keys Village-The Brethren Home Community to contact listed employers and references, verify information and reports for any agency to evaluate my suitability for employment. I also agree to hold Cross Keys Village – The Brethren Home Community harmless from any result of such investigation.

I hereby authorize any former employer, person, firm, corporation, school, and/or government agency to answer any and all questions and to release or provide any information with their knowledge or reports. I agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge or record.

I certify that I am of legal age to work in the job that I have applied for, that I am legally permitted to work in the United States of America and if offered employment will provide documents as required by Federal Law.

I understand that the acceptance of this application does not indicate there are any positions available and does not obligate Cross Keys Village-The Brethren Home Community in any way.

If conditionally offered employment, I agree to be subject to an examination by a Physician (M.D. or D.O.) currently licensed to practice in the Commonwealth of Pennsylvania, as required by regulations, or if I am disabled, the essential job functions with reasonable accommodations as necessary. A pre-employment physical, functional screen, and drug test will be required before any applicant begins employment. If all other requirements have been met, any job offer is contingent upon the results of these tests.

I understand and agree that if I am accepted for employment with Cross Keys Village – The Brethren Home Community, either I or Cross Keys Village – The Brethren Home Community may terminate the employment relationship at any time, for any reason, with or without cause or notice.

I hereby authorize my police record to be released to Cross Keys Village - The Brethren Home Community (if applicable). I do hereby release you, as the custodian of such records, from any and all liability for damages of whatever kind, which may at any time result to me, because of compliance with this authorization. I further understand that my employment is contingent on a conviction record which is free of any crime, the circumstances of which substantially relate to the activities engaged in by Cross Keys Village - The Brethren Home Community.

By submitting my application for employment and clicking submit below, I hereby accept this as my electronic signature which confirms my representation and qualifications for the position(s) applied for above.

* Signature (type name):

* Date: