1. APPLICATION FOR EMPLOYMENT: Complete all applicable information. This includes all required fields and contact information.

2. CRIMINAL BACKGROUND CHECK: All applicants must undergo a criminal background check. Please complete all information except Part II on The Request for Criminal Background Check. Some information has been provided for you. Nursing and Personal Care Home Applicants Only: If you have NOT been a continuous resident of The Commonwealth of Pennsylvania for The Entire Two Years (without interruption) immediately preceding the date of application for employment or currently live out of state, you must complete both the Request for Criminal Record Check and the FBI Background Check Transmittal Form.

3. HONESTY IN EMPLOYMENT STATEMENT: I am a sincere applicant for employment at this facility. Nursing and Personal Care Home Applicants Only: I affirm that I am not contracted or employed by a Federal or State Government Agency. Further, I understand that by falsely representing myself as a sincere employment applicant but am really an agent of a government agency; I discredit myself and the government agency I represent. Falsely representing myself will also provide just cause to immediately terminate my employment without notice.

4. EMPLOYMENT AT WILL STATEMENT: I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written documentation or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

5. ADA and EEO COMPLIANT: Title I of the Americans with Disabilities Act of 1990 prohibits discrimination against qualified individuals with disabilities in job application procedures, hiring, firing, advancement, compensation, job training and other terms, conditions and privileges of employment. Title VII and the Civil Rights Act of 1991 prohibits discrimination against a job applicant, current employee, or former employee with respect to hiring, firing, compensation, terms, conditions or privileges of employment. Federal and state laws define which groups of persons are protected by the law including: race, color, national origin, religion, sex, age, pregnancy, and childbirth, disability, and veteran status.

6. SHARING APPLICATION INFORMATION: This facility is associated with other nursing and personal care facilities as well as various other companies. Please check companies for which you wish to be considered for employment on the application:

Chicora Medical Center, Chicora, PA
Sugar Creek Rest, Worthington, PA
Trinity Living Center, Grove City, PA
Countryside, Mercer, PA
Fair Winds Manor, Sarver, PA
South Fayette Nursing Center, Markleysburg, PA
Henry Clay Villa, Markleysburg, PA
West Haven Manor, Apollo, PA

Pine Tree Villages, West Middlesex, PA
Newberry Apartments, Grove City, PA
Quality Pharmacy, Chicora, PA
Nurse Aide Training Program, Butler, PA
Quality Life Services Corporate Office

The applicant hereby authorizes this company to check all references and it is understood that false statements on the application may be considered sufficient cause for dismissal. Filing of this application does not indicate there are any positions open and does not in any way obligate this company. Nursing and Personal Care Home Applicants Only: I do verify that I have never been convicted, by court of law, or committed of any act of abusing, neglecting or mistreating an elderly individual, physically, verbally or financially. I do also verify that I have never been found guilty of abusing, neglecting or mistreating a nursing home or personal care resident by any State Nurse's Aide Registry or Licensing Authority. If at any time during my employment this statement is found to have been untrue, I understand it will result in immediate termination of employment.

By ckecking this form, I verify that all the application information is true, complete and correct to the best of my knowledge.