Application:

Please fill out before interview

Are you 18 years or older?

Date of Application

If not, do you have a work permit?

If so, what dates, department, position, and who was your supervisor?

If yes, please explain.

Position

Type of Position Applying for

Salary Desired

I will work (Check all that apply)

Any Shift

Weekends

Holidays

Rotating Shifts

Education & Training

Did you attend a College, University, or Technical School

Type of Degree

Major Subject

Name of School

City and State

Did you attend a College, University, or Technical School

Type of Degree

Name of School

Major Subject

City and State

High school last attended

Type of Degree

Name of School

Major Subject

City and State

License

Date

Type of License

Number

Please add any other certifications or training you consider relevant

Employment Record

List the most recent employment first

Employer 1

Start Date 1

Final Salary 1

Supervisors Name

Full Address

Final Position Title 1

End Date 1

Phone Number

Position Description

Reason for leaving

Employer 2

Start Date 2

Final Salary 2

Supervisors Name

Full Address

Final Position Title 2

End Date 2

Phone Number

Position Description

Reason for leaving

Employer 3

Start Date 3

Final Salary 3

Supervisors Name

Full Address

Final Position Title

End Date 3

Phone Number

Position Description

Reason for leaving

References

list 3 persons other than relatives or supervisors above.

Please include Name, relationship, mailing address, title,

and phone number

Reference 1

Reference 2

Reference 3

Federal, state and local laws and regulations prohibit discrimination on the basis of race, color, religion, national origin, ancestry, gender, disability, veteran status and age. The information on this application is not solicited for, nor shall it be used for the purpose of unlawful discrimination.

CHRIST THE KING MANOR IS AN EQUAL OPPORTUNITY EMPLOYER

PLEASE READ CAREFULLY BEFORE SIGNING

I hereby certify that the information that I have provided in this employment application is true and complete to the best of my knowledge. I understand that if I am hired, the discovery of any false information provided, any relevant information omitted on this application or in the interview (no matter when discovered) or any crime committed designated under Act 13 of 1997 shall be sufficient cause for termination of employment.

I authorize and instruct Christ the King Manor to make whatever inquiries it deems necessary of any person or organization to verify any of the information I have provided in this application and to determine my qualifications and abilities. I understand that a criminal background check will be completed by the appropriate law enforcement agency.

I release all persons and/or organizations from any and all liability which might arise in connection with supplying information in connection with my application. If hired, I also release Christ the King Manor from any and all liability which may arise in connection with providing information to any person or organization regarding my employment history and other matters as may be necessary.

I understand that if hired, prior to my first date of employment I will obtain a Medical Certification of my Fitness for Duty. I also understand that I will be required to undergo and pass a drug test prior to employment.

I understand that if hired, the first ninety (90) days will be an initial probationary period and I must satisfactorily complete a minimum of three (3) months of employment. The successful completion of the orientation/evaluation period does not guarantee my employment for any period of time thereafter. In addition, Christ the King Manor is an at-will employer.

I swear and affirm that I have disclosed any convictions of a felony or misdemeanor; and I have never been dismissed from employment due to abuse or neglect of clients or residents.

Your Signature

Thanks for submitting!

Application:

Position

Education & Training

Employment Record​

References

Employment Record