Contact us in Everett, Washington

 
Address: 2520 Madison St, Everett WA 98203

Phone: (425) 356-2100

E-mail: dlopes@sunriseview.org

Fax: (425) 356-2137

Business Office Hours: 9:00 AM - 4:30 PM


 
 
 
 
 
Statement of Intent Upon Hire
Sunrise View Retirement Villa & Convalescent Center is a DRUG FREE and NON-SMOKING/VAPING facility.

In accordance with Washington Administrative Code, Chapter 248-14-249,
it is the policy of Sunrise View to do a Criminal History Disclosure and Background Inquiry.

This will be accomplished by using the Nursing Home Services Background Inquiry form, DSHS 09-653 (Rev. 04-2015).

If you have any questions regarding this procedure, please feel free to discuss this with the supervisor of the department you are applying to.
Application for Employment
Federal and State law prohibit discrimination in employment based on race, color, creed, age, sex, marital status or national origin. Sunrise View operates under the principle that employment is terminable-at-will by the employee or the employer.
 
(Please PRINT)
 
 
Date:
 
 
 
 
 
Position desired:
 
 
 
 
 
 
Shift
 
 
 
 
Part-time:
 
 
 
 
Full-time:
 
 
 
 
Date you can start work:
 
 
 
*******************************************************************************************************************************************************
 
 
Name
 
 
 
 
Social Security #:
 
 
 
 
 
Address
 
 
 
 
City:
 
 
 
 
Email:
 
 
 
 
 
State
 
 
 
 
Zip code:
 
 
 
 
Phone#:
 
 
 
 
 
In emergency notify:
 
 
 
 
Phone:
 
 
 
*******************************************************************************************************************************************************
 
 
Are you currently employed?
 
 
 
 
What is your job:
 
 
 
 
Professional license(s) held:
 
 
 
Additional training:
 
 
*******************************************************************************************************************************************************
Please list previous 5 years work history – Permanent and Temporary
 
 
Employer name:
 
 
 
 
Address:
 
 
 
 
 
Phone #:
 
 
 
 
Dates employed: From
 
 
To
 
 
 
 
Hourly rate/Salary: Start
 
 
To
 
 
 
 
 
Job title:
 
 
 
 
Supervisor:
 
 
 
 
Work performed:
 
 
 
Reason for leaving:
 
 
*******************************************************************************************************************************************************
 
 
Employer name:
 
 
 
 
Address:
 
 
 
 
 
Phone #:
 
 
 
 
Dates employed: From
 
 
To
 
 
 
 
Hourly rate/Salary: Start
 
 
To
 
 
 
 
 
Job title:
 
 
 
 
Supervisor:
 
 
 
 
Work performed:
 
 
 
Reason for leaving:
 
 
*******************************************************************************************************************************************************
 
 
Employer name:
 
 
 
 
Address:
 
 
 
 
 
Phone #:
 
 
 
 
Dates employed: From
 
 
To
 
 
 
 
Hourly rate/Salary: Start
 
 
To
 
 
 
 
 
Job title:
 
 
 
 
Supervisor:
 
 
 
 
Work performed:
 
 
 
Reason for leaving:
 
 
*******************************************************************************************************************************************************
 
 
Employer name:
 
 
 
 
Address:
 
 
 
 
 
Phone #:
 
 
 
 
Dates employed: From
 
 
To
 
 
 
 
Hourly rate/Salary: Start
 
 
To
 
 
 
 
 
Job title:
 
 
 
 
Supervisor:
 
 
 
 
Work performed:
 
 
 
Reason for leaving:
 
 
*******************************************************************************************************************************************************
 
 
Employer name:
 
 
 
 
Address:
 
 
 
 
 
Phone #:
 
 
 
 
Dates employed: From
 
 
To
 
 
 
 
Hourly rate/Salary: Start
 
 
To
 
 
 
 
 
Job title:
 
 
 
 
Supervisor:
 
 
 
 
Work performed:
 
 
 
Reason for leaving:
 
 
*******************************************************************************************************************************************************
 
 
Applicant signature
 
 
 
 
Date
 
 
 
Employment Reference Request & Authorization
 
 
To:
 
 
 
 
Re: Applicant name:
 
 
 
 
 
Att:
 
 
 
 
S.S. #:
 
 
 
 
 
Phone:
 
 
 
 
Position Applied for:
 
 
 
I understand that past employers may be contacted per phone and/or written request and that both positive and negative information will be requested. I hereby authorize the release of any information regarding my work record. I understand that if employed, prior to return of reference information, my continued employment is contingent upon acceptable references and that any false statements or omissions on my application shall be considered sufficient cause for dismissal.
 
**Applicant Signature
 
 
 
 
Date
 
Sunrise View considers references to be an important part of the selection of new employees and will treat all references with confidentiality and professionalism. We thank you for your time and assistance in this process.
 
Signature of supervisor requesting information
 
 
 
 
Date
 

To be completed by previous employer:
 
 
States he/she was employed by you from
 
 
 
 
to
 
 
 
 
 
Working in the capacity of
 
 
 
 
He/she has applied for position of
 
 
 
 
How long have you known the applicant?
 
 
 
 
Is the applicant related to you?
 
 
If yes, how?
 
 
 
 
He/she was employed by you from
 
 
 
 
to
 
 
 
 
 
 
What was the position or job held?
 
 
 
 
 
 
Why did the applicant leave your service?
 
 
 
 
 
 
If company policy permits, would you rehire?
 
 
 
 
 
If not, please explain:
 
 
 
Please give a short summary of applicant’s skills and limitations:
 
 

 
Quality of work
 
 
 
Quantity of work
 
 
 
Dependability
 
 
 
Cooperation
 
 
 
General ability
 
 
 
Character
 
 
 
Initiative
 
 
 
Appearance
 
 
 
Needs Supervision
 
 
 
Needs Counseling
 
 
 
Average Monthly Absence
 
 
 
Would you recommend we hire this person for this position?
 
 
 
Remarks:
 
 
 
Completed by:
 
 
Facility:
 
 
Date:
 
 
 
When completed, please fax to: 425-356-2235
 
Sunrise View 2520 Madison Street Everett, WA 98203
 
 
 
Are you interested in employment opportunities at Sunrise View?