Courtland Manor Nursing and Convalescent Home

Employment Application- Laundry and Housekeeping

Date of Application

Name: Last First Middle Init

Address:

Phone #

Are you 18 or 0ver? Yes No

Employed Now?  Yes No

Can we contact present employer?  Yes No

Education: High School Highest grade completed  9 10 11 12

College Degree Yes No
      If Yes: BA MBA
      Field of Study

Were you ever in Armed Forces?  Yes No
      If Yes: Dates of Duty  From To

Professional Licenses and/or Certifications (please list license type and license #):

Present and Past employers last 5 years (Most recent first)

Employer #1
Dates of Employment:  From To
Position
Employer
Address  
Supervisor Name
Phone #

Employer #2
Dates of Employment:  From To
Position
Employer
Address  
Supervisor Name
Phone #

Employer #3
Dates of Employment:  From To
Position
Employer
Address  
Supervisor Name
Phone #

Employer #4
Dates of Employment:  From To
Position
Employer
Address  
Supervisor Name
Phone #

Employer #5
Dates of Employment:  From To
Position
Employer
Address  
Supervisor Name
Phone #

Have you ever been convicted of a crime  Yes No

If yes: For what and when
       Conviction Date
       Conviction Date

Primary Position desired

Will you accept another position Yes No
      if yes: What Position

Available to work:
      Week ends Yes No
      Holidays Yes No