Americus Campus (229) 931-5914 Requirements ... - Magnolia Manor

Americus Campus (229) 931-5914
The next scheduled C.N.A. Training Class will begin on September 24, 2012. The deadline to apply
for these classes is August 31, 2012.
The classes are provided by the Flint River Chapter of the American Red Cross. If you are selected by
Magnolia Manor, we will provide these classes to you at no charge.
Requirements for the Program:
Minimum Age – 21
High School Diploma or GED
Successfully complete:
o Interview with Assistant Director of Nursing
o Criminal Background Check
o Pre-Employment Drug Screening
Must commit to a 4-week course
Must be willing and able to work 12 hours shifts
The classes are scheduled from Monday – Friday from 9:00 am to 3:00 pm and will last approximately
four (4) weeks. First Aid and CPR certification will also be offered during the training program.
Upon successful completion of the class, participants may be offered a Temporary Full Time position
with Magnolia Manor to prepare for the State of Georgia Certified Nursing Assistant exam. You will
have 120 days from the beginning of the N.A. Class to successfully obtain your license. Failure to
successfully obtain your license will result in termination of your employment with Magnolia Manor.
I have read and understand the above requirements for participation in the C.N.A. Training
Program. I understand this does not represent an express or implied employment contract for any
duration between Magnolia Manor and its employees; either party has the right to terminate the
employment relationship at any time, for any reason. Nor does this create any terms or conditions of
employment.
________________________ ____________________________ _______________
Please Print Name Signature Date
Revised 8/22/12

Application
For Employment
We consider applicants for all positions without regard to race, color, religion, creed, gender, national
origin, age, disability, marital or veteran status, or any other legally protected status.
Position(s) Applied For
Please print and fill in completely
Date of Application
How did you learn about us?
Advertisement Relative Inquiry
Employment Agency Friend Other ( _____________________________)
Last Name First Name Middle Name
Address Number Street City State Zip Code
Telephone Number(s)
Social Security Number
Best time to contact you at home is: _____________________________________________________________
If you are under 18 years of age, can you provide proof of your eligibility to work? Yes No
Have you ever filed an application with us before? Yes No If yes, give date: _________
Have you ever worked for any Magnolia Manor facility? Yes No If yes, give date: _________
Do any of your friends or relatives, other than spouse, work here? Yes No
Are you currently employed? Yes No
May we contact your present employer? Yes No
Proof of citizenship or immigration status will be required upon employment. Are you prevented from lawfully
becoming employed in this country because of Visa or Immigration Status? Yes No
Date available to work ____/____/____ What is your desired salary range? _______________________
Time available for work: Full-time (please indicate 1 st , 2 nd , or 3 rd shift)
Part-time (morning, afternoon, or evening)
Temporary (please indicate dates available ____/____/____ to ____/____/____
Are you currently on “lay-off” status and subject to recall? Yes No
Can you travel if a job requires it? Yes No
Have you ever been convicted of a felony? Yes No
A criminal record does not constitute an automatic bar to employment and will be treated only as it relates to the job in question.
Revised 2/12
WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Education
Elementary
Name & Address
of School
Course of
Study
Years
Completed
Diploma
Degree
High School
Undergraduate
College
Graduate
Professional
Other
Specialized Skills (Check Skill)
____ Terminal ____ Spreadsheet ____ Other Skills List: ________________________
____ PC/MAC ____ Word Processing ________________________
____ Typewriter ____ Shorthand ________________________
____ WPM
________________________
Other Qualifications, Professional Affiliations, Training, Etc.
Revised 2/12

Employment Experience
Start with your present or most recent job. Include any job-related military service assignments and volunteer
activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities
or other protected status.
Employer 1 Dates Work Performed
From To
Address
Telephone Number(s)
Title
Reason for Leaving
Supervisor
Pay Rate/Salary
Start Final
Employer 2 Dates Work Performed
From To
Address
Telephone Number(s)
Title
Reason for Leaving
Supervisor
Pay Rate/Salary
Start Final
Employer 3 Dates Work Performed
From To
Address
Telephone Number(s)
Title
Reason for Leaving
Supervisor
Pay Rate/Salary
Start Final
Employer 4 Dates Work Performed
From To
Address
Telephone Number(s)
Title
Reason for Leaving
Supervisor
Pay Rate/Salary
Start Final
Please continue on a separate sheet of paper should you need additional space.
Revised 2/12

References
1. ( )
Name
Phone
Address (include street, city, state, and zip code)
2. ( )
Name
Phone
Address (include street, city, state, and zip code)
3. ( )
Name
Phone
Address (include street, city, state, and zip code)
Applicant’s Statement
I certify the answers given herein are true and complete.
I authorize investigation of all statements contained in this application for employment as may be necessary in
arriving at an employment decision.
This application for employment may be considered active for a period of time not to exceed 45 days. Any
applicant wishing to be considered for employment beyond this time period should inquire as to whether or not
applications are being accepted at this time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment
relationship with Magnolia Manor is of an “at will” nature, which means that the employee may resign at any
time and Magnolia Manor may discharge employee at any time with or without cause. It is further understood
this “at will” employment relationship may not be changed by any written document or by conduct unless an
authorized executive of Magnolia Manor specifically acknowledges such change in writing.
In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand, also, I am required to abide by all rules and regulations of
Magnolia Manor.
___________________________________________
Signature of Applicant
________________________
Date
Revised 2/12

Magnolia Manor, Inc.
Substance Abuse Policy
Notice to Applicants and Employees
As a part of the State of Georgia Workers’ Compensation Drug-Free Workplace Certification Program (O.G.C.A.
Section 34-9-410 through 421 (1993)), the Department of Transportation’s (DOT’s) Procedures for
Transportation Workplace Drug Testing Programs (49 CFR Part 40) and the federal and state Drug-Free
Workplace Programs, where applicable, Magnolia Manor, Inc (Company) has established a Substance Abuse
Program which will become effective October 15, 1997.
This policy establishes the Company’s position on the use or abuse of alcohol, drugs or other controlled
substances by its applicants and employees. It is a part of the Company’s commitment to safeguarding the health
of its employees, to providing a safe place for its employees to work and to supplying its customers with the
highest quality products and services possible. Because substance abuse, either while at work or away from work,
can seriously endanger the health and safety of employees and render it impossible to supply quality products and
services, the Company has established this program to detect users and remove abusers of alcohol, drugs or other
controlled substances. The Company is committed to preventing the use and/or presence of these substances in the
workplace.
All members of management and employees of the Company will be covered by this policy. The details of the
policy will be explained to applicants and employees. The essence of the policy provides for:
a) Drug testing of applicants (where confirmed positive drug test will result in denial of employment;
b) Drug testing of current employees randomly, where reasonable suspicion exists for possible substance
abuse, after accidents, and after rehabilitation;
c) Any employee who receives a confirmed positive drug test will be removed from the job and referred to
rehabilitation at his/her own expense, and/or disciplined in accordance with company policy up to and
including termination. The Company will maintain a Resource File which contains information on
employee assistance and rehabilitation resources in the administrative offices. Refusal to agree to be
referred to rehabilitation, or refusal to submit a drug test, will result in termination;
d) Any applicant or employee who receives a positive confirmed drug test result may contest or explain the
result to the Company within five working days after written notification of the positive test result; and
e) Any information pertaining to this program will be kept confidential on a need to know basis and will not
be released unless required by law.
Thank you for your cooperation in helping Magnolia Manor, Inc. do its part to achieve a Drug Free America
___________________________________________
Signature
______________________
Date
Revised 2/12

Magnolia Manor, Inc.
AUTHORIZATION TO RELEASE INFORMATION
I hereby state that the information given by me in my employment application is true and complete in all respects.
I understand that in consideration of my application, an investigation may be conducted of my past employment
and activities. I authorize past employers, personal references and any other persons with whom I am acquainted
to answer all questions asked concerning my previous employment record, ability, military service, educational
background, medical history, criminal record history, credit history, driving record, workers’ compensation
claims, character and reputation. I release all persons including past employers, credit bureaus and government
agencies from any liabilities or damages on account of having furnished such information in good faith. All credit
information will be furnished in compliance with the Fair Credit Reporting Act (FCRA),
In consideration of my application for employment, I authorize Information On Demand and/or its agents to
conduct such an investigation, and release Magnolia Manor, Inc., including its officers, employees, agents and
representatives from all liability or responsibility for this investigation. I understand that the information
requested below regarding gender, race and date of birth are for the sole purpose of gathering the above
information accurately, and will not be used to discriminate against me in violation of any law. I understand that
any initial employment offer will be contingent until all information is obtained and processed and may be
subsequently withdrawn based on the results of this investigation.
I understand that a consumer report may be requested or an investigation conducted. I further understand that if
employment is denied in whole or part because of information obtained from a consumer reporting agency, I have
the right to make a written request within a reasonable period of time to receive information about the scope and
nature of the investigation. A telephone facsimile (FAX) or a photographic copy of this authorization shall be
valid as the original.
___________________________________ ___________________________________
APPLICANT’S FULL LEGAL NAME (PRINT)
SOCIAL SECURITY NUMBER
____________________________________________________
MAIDEN OR ANY OTHER NAMES USED
____________________________________________________
DRIVER’S LICENSE NUMBER/STATE
____________________________________________________
CURRENT ADDRESS (STREET)
____________________________________________________
CITY, STATE, ZIP AND COUNTY (HOW LONG)
____________________________________________________
PREVIOUS ADDRESS (STREET)
____________________________________________________
CITY, STATE, ZIP AND COUNTY (HOW LONG)
____________________________________________________
RACE
____________________________________________________
GENDER
____________________________________________________ ____________________________________________________
DATE OF BIRTH SIGNATURE DATE
************************************* FOR COMPANY USE ONLY *************************************
REPORT TO :____________________________ TELEPHONE # __________________
FAX # __________________________________ FACILITY CODE ________________
Authorization to Release Information form revised 1/05
Revised 2/12