* 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 21 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Do you have a valid level 1 fingerprint clearance card from the State of Arizona?:

Yes   No

* Have you ever been denied a Fingerprint Clearance Card?:

Yes   No

* Can you travel locally if the job requires it?:

Yes   No

* Can you travel outside of Maricopa County if the job requires it?:

Yes   No

* Have you ever been discharged from any employment or asked to resign?:

Yes   No

If Yes, please explain:

* Have you ever been convicted of a felony or a misdemeanor? (A conviction will not necessarily result in the denial of employment):

Yes   No

If Yes, please explain:

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* Do you have any friends or relatives employed by Foundation for Senior Living?:

Yes   No

If yes, please provide their names and relationship to you:

* 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:

* Please tell us why you want to work at FSL:

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time On-call

* Hourly rate/salary desired:

* Are you currently employed?:

Yes   No

If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
*	* Yes   No		*
	Yes   No
	Yes   No

Give your full employment record, starting with your current or most recent employment. Please DO NOT refer us to RESUME.

Dates Employed	Employer Name & Address	Employer Phone
From: * To: *	* *	*
Job Title	Supervisor Name & Title	May we Contact?
*	* *	* Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
*	*	Start: * End: *

Dates Employed	Employer Name & Address	Employer Phone
From: * To: *	* *	*
Job Title	Supervisor Name & Title	May we Contact?
*	* *	* Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
*	*	Start: * End: *

Dates Employed	Employer Name & Address	Employer Phone
From: * To: *	* *	*
Job Title	Supervisor Name & Title	May we Contact?
*	* *	* Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
*	*	Start: * End: *

Name	Professional Relationship	Phone Number	Email
*	* Ex Co-Worker   Colleague   Supervisor   Ex- Supervisor    Other	*
*	* Ex Co-Worker   Colleague   Supervisor    Ex Supervisor   Other	*
*	* Ex- Coworker   Colleague   Supervisor    Ex Supervisor    Other	*

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

Please Note: some of our funding sources require a fingerprint clearance by the Arizona Department of Public Safety. If you are hired for a position that requires fingerprint clearance, you will be asked for your clearance card (if you have one) or you will be fingerprinted on or before your first day of work.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date:

I understand that the Foundation is an Equal Opportunity/Affirmative Action employer and that applications are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, status related to public assistance, and any other legally protected status.

I agree that, should an employment offer be extended to me and accepted, I will fully adhere to the policies, rules and regulations of employment of the Foundation.

I understand that neither the policies, rules, regulations of employment nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract.

I understand that, if employed, my employment is considered "at will" and may be terminated with or without cause, and with or without notice, at any time, at the option of either the Foundation or me.

Questions regarding these statements should be directed to the Foundation Human Resources department or to a Foundation employment interviewer before signing.

I acknowledge that I have read and understand the above statements.

Reference Authorization

I hereby authorize any of my former employers or personal references to furnish the Foundation for Senior Living and its affiliated corporations with any information they may have regarding my former employment and/or professional practices. I hereby release such employers or personal references from any and all liability of whatever kind, which, at any time, could result from the information provided.

Notice & Disclosure to Employment Applicant Regarding Procurement Of a Consumer Report

As part of its employment screening and selection procedures, the Foundation for Senior Living and affiliate corporations require a background and reference check for employees. The objective of the investigation is to verify the accuracy of the information provided through the application process, check references and identify other factors that might be relevant to Foundation for Senior Living and affiliate corporations' employment requirements. Prior to being hired and during the course of your employment, if hired, we may obtain a consumer report and/or an investigative consumer report about you for employment purposes. This report may include, but is not limited to: Department of Motor Vehicles, current and former employers, credit reporting agencies, military records, school records, professional and personal references, criminal conviction records, information regarding your character, experience, work habits, previous job performance, and the reasons for termination at previous places of employment.