Wesley Towers, Inc. 
700 Monterey Place 620-663-9175
Hutchinson, KS 67502 


NOTE TO APPLICANT: Wesley Towers is committed to be an Equal Opportunity Employer.  All candidates are considered for employment without unlawful discrimination based on sex, race, religion, age, color, familial status, pregnancy, disability, national origin, ancestry, military status, genetic information, or any other unlawful reason. Wesley Towers is a Family Medical Leave Act (FMLA) covered employer. For additional information go to: https://www.dol.gov/whd/fmla/

All applications will be kept on file for 60 days. Incomplete or illegible applications will NOT be processed.

Personal Data

*required fields
Last Name Please enter your last name. * First Name Please enter your first name * Middle Initial Please enter you middle initial. *
Present Address Please enter your address. *
City Please enter your city * State Please enter your state * Zip Code Please enter your zip code *
Home Telephone Please enter your home telephone number*  Cell Phone Number Please enter your cellphone number.
Email Address Please enter your email address. *
Are you legally eligible for employment in the U.S.A.? *
Please signify at the top section of the form whether you are legally eligible for US employment Yes No
State age (if under 18)
Maiden name or other last names used Please enter your maiden namd or other last names used.
Were you previously employed by us? Please tell us whether you were previously employed by us or not Yes No*  If Yes, when?
Name during employment (if different than above)
What was your position?
Job Preferences
Positions applied for Please tell us the positions applied for. * 
Rate of pay expected
$ Please tell us the rate of pay expected/hour *
If selected, on what date will you be available for work Please indicate the date you will become available for work *
Would you work:* 
Full Time Part Time  PRN (Nursing Only) Weekends Only (Nursing Only) Please tell us whether you expect to work full time or part time Seasonal
 Hours and days available:*
Shift Preference:* 
1st | 2nd | 3rd
Office skills, other skills or qualifications
Please indicate proficient skills and other special training that may assist you in performing the position for which you are applying: (i.e. Word, Excel, Publisher, Powerpoint, Website, Email, etc)
Have you ever been found guilty of any crime, including DUI, other than a traffic violation?
Please signify at the top section of the form whether you are legally eligible for US employment Yes No *Please indicate whether you have been convicted of a crime.   
If yes, list all convictions and the year.
It is important to list any misdemeanor, felony, or juvenile adjudication on your application. Convictions are not an absolute bar to employment, but certain enumerated crimes are prohibited by the state of Kansas. Factors such as the date of conviction, seriousness and nature of the conviction will all effect the consideration for the position.
Education
  High School / GED Equivalent College /Univ. Other (Business, Technical, Etc.)
Name of School
City / State
Did you Graduate? Yes No Yes No Yes No
Years Completed
Course/College Major
Degree/# of Hours
Military Service
Are you a veteran of the Armed Forces? Yes No

Check all current licenses and certifications in Kansas
RN LPN CMA CNA    List #    

Expiration Date

How did you hear about us?
Employee Referral Former Employee Walk In  
Social Media (please specify) Wesley Towers Web Site Newspaper Ad
Other
If referred by an employee, state name:
If social media, please specify the social media:
Do you have any relatives working at Wesley Towers? Yes No
If yes, list name and relationship:
List present or most current Employment
Name and Address of Company Telephone Name of Supervisor Position/Title & Duties
From Mo/Yr To Mo Yr Salary Pr Hr Total Hrs Per Week
Reason for Leaving
Other or Previous Employment
Name and Address of Company Telephone Name of Supervisor Position/Title & Duties
From Mo/Yr To Mo/Yr Salary Pr Hr Total Hrs Per Week
Reason for Leaving
Name and Address of Company Telephone Name of Supervisor Position/Title & Duties
From Mo/Yr To Mo/Yr Salary Pr Hr Total Hrs Per Week
Reason for Leaving
Name and Address of Company Telephone Name of Supervisor Position/Title & Duties
From Mo/Yr To Mo/Yr Salary Pr Hr Total Hrs Per Week
Reason for Leaving
Add Additional Previous Employment
May we contact your present employer for references? Yes No
Abuse Neglect Exploitation Crime
Have you been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law or have a crime against a person (i.e., battery) or theft in the last five years? *
Please signify if you have been found guilty of abuse/neglect/exploitation Yes No Please signify if you have been found guilty of abuse/neglect/exploitation   
Have you had a finding entered at the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property? *
Please signify if you have been found guilty of abuse/neglect/exploitation Yes No Please signify if you have been found guilty of abuse/neglect/exploitation   
Have you had a disciplinary action in effect against your professional license by a state licensure body as a result of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property? *
Please signify if you have had disciplinary action against your license as a result of abuse/neglect/exploitation Yes No Please signify if you have had disciplinary action against your license as a result of abuse/neglect/exploitation   
If you answered yes to any of these three questions, you are not eligible to work at Wesley Towers.
Personal References
List names and other information of three people other than relatives and previous supervisors listed on this application who would know of your qualifications for the position for which you are applying.
Name and Occupation Address, City and State Telephone Number
Please fill out 3 Personal References * Please fill out 3 Personal References * Please fill out 3 Personal References *
Relationship & Years Known
Name and Occupation Address, City and State Telephone Number
Please fill out 3 Personal References * Please fill out 3 Personal References * Please fill out 3 Personal References *
Relationship & Years Known
Name and Occupation Address, City and State Telephone Number
Please fill out 3 Personal References * Please fill out 3 Personal References * Please fill out 3 Personal References *
Relationship & Years Known

Employment At-Will
Wesley Towers is an “at-will” employer. This means that your employment with Wesley Towers is based on mutual consent and both Wesley Towers and the employee have the right to terminate employment at any time with or without cause or justification and with or without notice. Wesley Towers does not sign or recognize contracts of employment.

 

Notice of Intent to Obtain Consumer Report
I understand that as a condition of my consideration for employment, Wesley Towers may obtain a consumer report that includes, but is not limited to, employment and education verifications, social security verification, criminal and civil history, personal interviews, DMV records, Medicare fraud, any other public records and any other information bearing on my character, general reputation, personal characteristics and trustworthiness.

Please Read and Sign (Electronically) Below

I understand that all offers of employment from Wesley Towers are contingent on passing the drug/alcohol screening and pre-employment physical (if applicable). Any contingent offer of employment will be withdrawn if the applicant tests positive for any illegal drugs/alcohol, does not pass the pre-employment physical or fails to disclose all or prohibited convictions on background checks.

I affirm that I have given true and complete information on this application. I have also read, understand, and accept the conditions of employment stated on this application and further authorize the release of information as stated above.

I understand that false information or omissions on this application, including failure to list all past employers for the past 10 years may result in the rejection of this application or may be grounds for dismissal if discovered at a later date.

I understand that a photocopy of this signed release will also serve as effective and valid as the original.

By electronically filling out your name and date in the below boxes, you hereby agree to have read and agree to follow the above disclosed agreement by Wesley Towers:

Your Full Name (Electronic Signature) Please electronically sign this form Date Please enter todays date at the bottom of the form