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F: 618-288-2299
6960 State Route 162
Maryville, IL 62062
Position Applied For : Date :
Name :
Address :
Phone :
Cell Home
Email :
If hired, can you provide written evidence that you are authorized to work in the U.S.? Yes No
Are you 18 years of age or older? Yes No
Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation? If yes, please specify:  Yes No
For reference purposes, have you worked or attended school under a former name?
If yes, please list former name: 
Yes No
Have you ever been employed here before?    If yes, when? Yes No
Have you ever applied here before?    If yes, when?  Yes No
Do you have any relatives who are currently employed at any BMA Management Community?    
If yes, give full name:
and community:
Yes No
Are you able to perform the essential functions of the job you are applying for?
If no, what accommodation would assist you?
Yes No
How did you hear about the company?

US Military Service
Branch of Service Rank & Type of Service
Served From Year Served Until Year
Training / Experience Received
Type of School Name and Location Course of Study #Years Degree/Diploma
Elementary & Jr. High
High School
College or University
Technical or Other
Military or Other

Employment Record
Company Name /Location Position Date Start/Left Pay Rate Reason for Leaving
Contact Person: Can we contact: Yes No
Contact Person: Can we contact: Yes No
Contact Person: Can we contact: Yes No
Contact Person: Can we contact: Yes No

Employment Preference

Position Desired : Earnings Desired:
Location Desired: Desired Hours/week: Shift Desired:
Career Objectives:
Employment Status Desired: Full Time Part Time Temporary Start Date:
Are you available to travel?   Yes No      Are you willing to relocate? Yes No
Please list any additional information that relates to your ability to perform the job for which you have applied, such as licenses, professional memberships, hobbies, etc:
Reference List

Provide information requested on three business/work or school references who are not related to you.  Include name/occupation/years known and address/phone.





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I certify that all information I have provided in order to apply for and secure employment with this employer is true, complete and accurate.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, or immediately discharge me from employment, whenever it is discovered.

I expressly authorize the employer, its representatives, employees or agents to contact and obtain information from all references, employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of the information provided by me in this application, resume or job interview.

The application will remain current for only 90 days from the date it was submitted. At the conclusion of that time, if the applicant has not heard from the employer and wishes to be considered for employment, it would be necessary for the applicant to reapply and complete a new application form.

I understand the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing the applicant from consideration for employment on the basis prohibited by applicable local, state or federal law.

I understand that Illinois is an “at will” employment state. BMA Management, Ltd. is an “at will” employer and each employee is an “at will” employee.

“At will” employment means that you are free to leave our employment at any time for any reason you choose, and we are free to terminate that employment at any time for any reason we choose. There is no contract or agreement of any kind etween any employee and or BMA Management, Ltd. as his or her employer, requiring that you work for us for any period in the future or that we continue to employ you for any period in the future.

Neither this application nor offer of employment can or does create a contract or agreement of employment for any specified period of time.

I certify that I have read the above Applicant Acknowledgement and accept all terms.

Accept   Yes No

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An Equal Opportunity Employer

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