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The  Villa
An Evergreen Eldercare Senior Living Community

Pre-Admission Questionnaire
Equal Opportunity Residence
(No discrimination on the basis of race, color, religion, ancestry, origin, age, or identification)
Current Living Status:
Accommodation Preference:

* I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and into the references and employers listed above to provide to you any pertinent information they may have.I acknowledge and do hold accountable the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specific period time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company officer. 

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I also understand that at anytime the company requests a drug screening test I will not refuse. 

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