Start Your Career at

The Cypress of Raleigh

The Cypress of Raleigh Club is an equal opportunity employer and makes all employment decisions without regard to race, color, national origin, religion, sex, sexual orientation, age, veteran, disability and all other protected areas. We deeply appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications.

Personal Information
Your Name*
First Last
Present Address*
Street Address Address Line 2 City State ZIP Code
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How long have you lived at present address?*
How long did you live at previous address?
Telephone Number*
Email Address*
Eligibility Requirements*
- Are you at least 18 years old?
- Are you legally eligible for employment in the USA?
- Can you provide verification of eligibility upon hire?
Date Available to Begin Work*
MM slash DD slash YYYY
Position(s) you are applying for*
- Prep Cook/ Line Cook
- C N A
Rate of pay expected per hour? ($)*
Work Status Needed*

Please list your preferred shift*

Day	Hours

Enter the day(s) of the week in the first column, and the hours you are available that day in the second column. Click the "plus" icon to add more days and hours.

Were you previously employed by The Cypress Club?*
What year were you previously employed by The Cypress Club?*
Please enter a number from 1980 to 2100.

Do you have any friends or relatives working for The Cypress Club?

Enter the names of any friends or relatives above. Click the "plus" icon to add additional names.

Have you ever been convicted of a felony, misdemeanor or offense other than minor traffic violations?*
Please explain including but not limited to date, type and offense resolution. Please do not disclose convictions that are expunged, sealed or annulled by the court (Note: Convictions will not automatically disqualify from employment depending on type and circumstances).*
Are you excluded from participation in Federal Health Care Programs?*
Please explain*
Employment Record
Company Name*
Positon Held*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Supervisor Name*
First
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Salary*
Reason for Leaving*
Employment Record #2
Company Name*
Positon Held*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Supervisor Name*
First
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Salary*
Reason for Leaving*
Add Third Employer?
- Yes, I have more employment information to add.
Employment Record #3
Company Name
Positon Held
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Supervisor Name
First
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary
Reason for Leaving
Add Fourth Employer?
- Yes, I have more employment information to add.
Employment Record #4
Company Name
Positon Held
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Supervisor Name
First
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary
Reason for Leaving
Periods of Unemployment
Do you have any periods of unemployment?*
Beginning of Unemployment*
MM slash DD slash YYYY

Please select the beginning of your period of unemployment.
End of Unemploymet*
MM slash DD slash YYYY

Please select the end of your period of unemployment, or if currently unemployed selected today's date.
Account for any time period that you were unemployed by stating the nature of your activities.*
Additional Employee Information
May we contact your present and former employer?*
If not, which employers do you not want us to contact?*
Why would you like to work at The Cypress Club?*
How did you hear about this job opportunity?*
Were you referred by a current Cypress Club employee?*
If yes, please state the name of the current employee*
High School Education Record
Name
State
Did you graduate?
GED Education Record
Where
State
College Education Record
Name
State
How long?
Course of Study
Degree
Other Education Record
Name
How long
Course of Study
Degree/Diploma
Additional Education Information

Certifications or Licensures (Include License #)

Name	License #

Enter the certification/license name in the first column and the license # in the second column. Use the "plus" icon to add more certifications/licensures.

List any other experiences, skills, hobbies or qualifications that may benefit our organization:

Use the "plus" icon to add more skills, hobbies or qualifications.

Military Service Record
Were you in the US Armed Forces?
What branch?*
Duty From*
MM slash DD slash YYYY
Duty To
MM slash DD slash YYYY
Rank at Discharge*
List duties in the service*
Professional References
NO RELATIVES PLEASE.
Reference 1*
Name Occupation Address Phone Number

Reference 2*

Name	Occupation	Address	Phone Number

To add more than the required two references, click the "plus" icon to add additional references.

Your Resume
Max. file size: 10 MB.
I UNDERSTAND:
1. that this application does not constitute an offer of employment and that my application may be rejected for any reason;
2. that giving false or misleading information on this form or in an interview or omissions of facts shall be considered sufficient grounds for denial or immediate termination if employment;
3. that I may be required to complete a medical history form and may be required to be examined by a medical professional designated by The Cypress Club of Raleigh, Inc.;
4. and that it I sustain any injury or illness in the employment of The Cypress Club of Raleigh, Inc., I agree that The Cypress Club of Raleigh, Inc. shall be entitled to receive full and complete reports and records covering any medical or related exams, and I authorize any and all such doctors, medical examiners, and hospitals to give to The Cypress Club of Raleigh, Inc. full and complete reports and records covering such examinations, conditions, care, and treatment related to or resulting from the alleged illness or injury.
AUTHORIZATION TO RELEASE INFORMATION: If I am given a conditional offer of employment, I authorize The Cypress Club of Raleigh, Inc. to make a complete investigation of me, including but not limited to: my past employment history, medical history, scholastic records, criminal records, abuse records, motor vehicle driving records, and to rely on such information sources. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephone facsimile (FAX) or photographic copy shall be as valid as the original. By signing below, I certify that I have not been convicted of an offense that would preclude working in a nursing facility. I also certify that I am not excluded from participation in federal health care programs. Furthermore, I understand that I will be subject to a search of the OIG List of Excluded Individuals, and that a comprehensive criminal background screening will be completed by a third-party organization acting on behalf of The Cypress Club of Raleigh, Inc. If the findings of that background screening result in a refusal to hire, I will be notified in writing and may request a copy of the findings from the third-party organization. I understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this employment application and any other employee-related documents are not contracts of employment, and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee.
Type your name here as your signature agreeing to the text above*
Email
This field is for validation purposes and should be left unchanged.

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Start Your Career at

The Cypress of Raleigh

Personal Information

Employment Record

Employment Record #2

Employment Record #3

Employment Record #4

Periods of Unemployment

Additional Employee Information

High School Education Record

GED Education Record

College Education Record

Other Education Record

Additional Education Information

Military Service Record

Professional References

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