PENN YAN MANOR

Name

FIRST NAMELAST NAME

MIDDLE IN

Address

PRESENT ADDRESS

Street Address Line 2

CITYSTATE

ZIP

CELLPHONE

E MAIL

example@example.com

POSITION APPLIED FOR?

WAGE/SALARY DESIRED?

DATE AVAILABLE FOR WORK?

AVAILABLE:

DAYSEVENINGSNIGHTS

APPLYING FOR

FULL TIMEPART TIMETEMPORARY

ARE YOU 18 YEAR OR OLDER?

YESNO

ARE YOU LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?

YESNO

HAVE YOU EVER PREVIOUSLY APPLIED TO OR BEEN EMPLOYED BY THIS COMPANY?

YESNO

Were you known by any other name at any job or school listed on this application?

If yes, when?

What name(s)?

At which school(s)/employer(s) were you known by this other name?

SCHOOLING

	NAME OF SCHOOL	LOCATION OF SCHOOL	DID YOU GRADUATE?	DEGREES RECEIVED
HIGH SCHOOL
COLLEGE
TRADE, BUISINESS
GRADUATE SCHOOL

Please list four persons, other than relatives, who we may contact about your professional work experience. Past supervisors are strongly preferred. Relationship Telephone Number

CONTACTS

	NAME	YEARS KNOWN	RELATIONSHIP	PHONE #
PERSONS 1
PERSONS 2
PERSONS 3
PERSONS 4

Please list your employment history below beginning with the most recent employer, include U.S. military service.

IF CURRENTLY EMPLOYED, MAY WE CONTACT EMPLOYER?

YESNO

Employer

City/State

TELEPHONE

Job Title

Supervisor

TELEPHONE

Dates Employed

From

To

Duties

Employer

City/State

TELEPHONE

Job Title

Supervisor

TELEPHONE

Dates Employed

From

To

REASON FOR LEAVING

MAY WE CONTACT

YESNO

Employer

City/State

TELEPHONE

Job Title

Supervisor

TELEPHONE

Dates Employed

From

To

Duties

MAY WE CONTACT

YESNO

I certify that the information given by me is true and complete to the best of my knowledge. - understand that if am employed, the discovery that I gave false information during the application process may result in immediate dismissal. Iauthorize the Company to which I am providing this application Penn Yan Manor Nursing Home to investigate all statements contained in this application and to request information about me from previous employers, educational institutions, and references. 1 expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release all parties (including the Company) and persons connected with any requests if for Information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information. employed, I release Penn Yan Manor Nursing Home from any liability for future references it may provide regarding my work history with Penn Yan Manor Nursing Home. Due to the large number of applications that Penn Yan Manor Nursing Home receives, f understand the Company cannot guarantee that my application will be considered for any or all open positions they may have or that my application will be considered for any specific time. In the event of employment, I understand that I am required to abide by all current and subsequently issued rules and regulations of the Company and that my employment may be terminated, at any time, with or without notice, by either party. 1 understand that this application is not a contract, offer or promise of employment and that if hired, ) will be an at-will employee. As such, I will be able to resign at any time for any reason. Likewise, Penn Yan Manor Nursing Home can terminate my employment at any time with or without cause, unless otherwise required by law. I further understand that no one other than Penn Yann Manor Nursing Home has the authority to enter intoan employment contract or agreement with me and that my at-will employment can be changed only by a written agreement

Signature of Applicant

Date

NOTE: PLEASE CALL 315-536-2311 IF YOU NEED ASSISTANCE COMPLETING THIS APPLICATION

EQUAL OPPORTUNITY EMPLOYER