Application Form

For a complete list of employment opportunities at Richfield Retirement Community, click here.

Download an application (PDF) or fill out the form below.

* Required

Contact Information

Name *
SSN
Address
City/State/Zip
Phone Number *
Email *
Today's Date

Job Preferences

Shift Preference
Type of Employment

Personal Information

Are you under 18 years of age?:
If yes, employment is subject to verification that you are of minimum legal age.
Position you are applying for
Date available for employment
Can you, after employment, submit verification of your legal right to work in the US?
Have you ever applied for employment with us before?
If yes, when?
Have you ever worked here?
If yes, from when to when
How were you referred to us?
Do you understand that you will be required to work holidays and/or weekends?
Have you ever been discharged or asked to resign from a position?
If yes, please explain
Is anyone related to you employed by Richfield?
If yes, please explain
Have you ever been convicted of a crime involving theft, violence, drugs, or any law involving moral turpitude (lying, cheating, or stealing)? A conviction will not automatically bar you from employment unless the crime is a "barrier crime" as set forth under Virginia law. The nature of the crime, date of conviction, and the relationship of the crime to the job sought will be considered in determining eligility for employment.
If yes, please explain

Education

Elementary or High School

School Name and Address
Course of Study XXXXX
Years Attended 1   2   3   4   5
Did you Graduate?
List Diploma or Degree

College

School Name and Address
Course of Study
Years Attended 1   2   3   4   5
Did you Graduate?
List Diploma or Degree

Other

School Name and Address
Course of Study
Years Attended 1 • 2 • 3 • 4 • 5
Did you Graduate?
List Diploma or Degree

Experience

Starting with the most recent, describe all paid, military and applicable voluntary experience. Describe the knowledge, skills and abilities that demonstrate your qualifications for this position. Use additional attachments if necessary.

Block A
Job Title
Employer
Address
Phone
Type of Business
Immediate Supervisor
Title
Salary (Start)
Salary (Final)
From (mm/yy)
Ending (mm/yy)
Duties
Number of Employees
Supervised
May we Contact
Reason for Leaving
Name, if different
Block B
Job Title
Employer
Address
Phone
Type of Business
Immediate Supervisor
Title
Salary (Start)
Salary (Final)
From (mm/yy)
Ending (mm/yy)
Duties
Number of Employees
Supervised
May we Contact
Reason for Leaving:
Name, if different
Block C
Job Title
Employer
Address:
Phone
Type of Business
Immediate Supervisor
Title
Salary (Start)
Salary (Final)
From (mm/yy)
Ending (mm/yy)
Duties
Number of Employees
Supervised
May we Contact
Reason for Leaving
Name, if different
Block D
Job Title
Employer
Address
Phone
Type of Business
Immediate Supervisor
Title
Salary (Start)
Salary (Final)
From (mm/yy)
Ending (mm/yy)
Duties
Number of Employees
Supervised
May we Contact
Reason for Leaving
Name, if different

Special Skills and Qualifications

Summarize special job related skills and qualifications acquired from employment or other experience.

References

Personal References, Not Former Employers or Relatives

Reference 1

Name and Occupation
Address
Telephone
Relationship
Occupation

Reference 2

Name and Occupation
Address
Telephone
Relationship
Occupation

Reference 3

Name and Occupation
Address
Telephone
Relationship
Occupation

Cover Letter

If you have one, copy and paste your cover into the space provided. If you don't have a standard cover letter, please tell us a bit about what you seek at Richfield.

Resume

If you have one, copy and paste your resume into the space provided. If you don't have a resume, please tell us a bit about yourself and what skills you have.

Job Applicant's Agreement, Certification & Release of Information

"The facts set forth above in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal if and when discovered."

"I hereby irrevocably appoint any officer or administrator of Richfield as my agent with full authroity to request, inspect, copy and otherwise have access to the following information on my behalf and in my stead to the extent that such information may relate to my past, present or future employement.

1. All personal information and records now and hereafter maintained by any agency of the State of Virginia or the United States in any existing or future information system within the meaning of the Federal Privacy Act of 1974 and the Virginia Privacy Protection Act of 1976 as the same may be amended from time to time.

2. All official records maintained by any agency or public body of the State of Virginia or the United States within the meaning of the Federal and Virginia Freedom of Information Act, as the same may be amended from time to time.

3. All records maintained by my present or past employers relating to my employment."

"I agree to be employed on a 90 calendar days' introductory period and that during this time I may be released or may resign without any bad effect on my employment record. In the event of employment, I understand that my employment is terminable at will any time for any reason during or after the introductory period. I agree to submit to a physical examination whenever requested, and if employed, I agree to abide by all present and subsequently issued personnel policies and rules of Richfield. I further understand that I must satisfy the requirements of a pre-employment or post offer drug screening process. I give permission for the facility to contact any person or agency mentioned by individuals listed as my references on my application for employment."