Application Name* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date of Birth MM slash DD slash YYYY Position Applying ForPlease click & select desired position...CaregivingHousekeepingDietary AideSupervisorActivitiesManagementDate You Can Start MM slash DD slash YYYY Salary at your last job How did you here about us?*Which community(s) are you applying for? Autumn Oaks – Slinger, WI Country View – Oak Creek, WI Golden Gardens – Milwaukee, WI Willow View - S Milwaukee, WI Crystal Bay -Racine, WI The Pillars at Crystal Bay Golden Harbor – Sheboygan, WI Larson House – Columbus, WI River View – Watertown, WI Are you available to work weekends?AlwaysNeverOnly SaturdaysOnly SundaysSometimes – give an explanation belowTell us about your availability, which days and times of a typical week are you available to work?*What makes you want to work in an assisted living community?*How would you describe the qualities of an exceptional Assisted Living Community team member?*Tell us about your career goals. In an ideal world, where do you see yourself in 5 years?*High School* Last Year Completed*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Did you graduate?* Yes No College Area of Study Years attended Did you graduate? Yes No Trade School Area of Study Years attended Did you graduate? Yes No Do you currently have any of the following licenses or certifications? (check all that apply) LPN C.N.A. MA Medication Management Fire Safety Safe Resident Handling Standard Precautions First Aide CPN Food Handlers Safety Other *If you choose other, please list here: Have you ever been employed by this company before?* Yes No If yes, when?* Do you have friends or relatives employed by Platinum Communities?* Yes No Please provide the name and relationship to you: Are you currently employed?* Yes No May we contact your employer?* Yes No N/A Do you have a valid drivers license?* Yes No Have you been convicted of Driving Under the Influence ("DUI"), in the last 7 years?* Yes No Have you ever been convicted of a crime - a felony or misdemeanor?* Yes No List all former employers for the past 5 years*Company NameCityManagers NamePhone NumberEmployment Started (Month/Year)Employment Ended (Month/Year)Reason For LeavingFinal Pay RateWhat was your favorite part about this job?Company NameCityManagers NamePhone NumberEmployment Started (Month/Year)Employment Ended (Month/Year)Reason For LeavingFinal Pay RateWhat was your favorite part about this job?Company NameCityManagers NamePhone NumberEmployment Started (Month/Year)Employment Ended (Month/Year)Reason For LeavingFinal Pay RateWhat was your favorite part about this job?Company NameCityManagers NamePhone NumberEmployment Started (Month/Year)Employment Ended (Month/Year)Reason For LeavingFinal Pay RateWhat was your favorite part about this job?Reference*NameAddressPhone NumberBusiness/Occupation Tell us why you would be a great addition to the Platinum Communities Family:*