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Please fill out before interview


I will work (Check all that apply)

Education & Training

Employment Record​

List the most recent employment first


list 3 persons other than relatives or supervisors above.

Please include Name, relationship, mailing address, title,

and phone number

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.



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.

Thanks for submitting!

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