Employment Application Form

Episcopal SeniorLife Communities

505 Mount Hope Avenue - Rochester, NY 14620

Name:
	First Name	Middle Initial	Last Name

Date:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Social Security #:

Cell/Pager/Message Number:

Email Address:

Nursing / Professional License
Certification No & Type :

Expiration Date:

Position or type of work designed:

Location desired (check all that apply):

	Episcopal Church Home
	Brentland Woods

	River Edge Manor
	Seabury Woods

Available to work:

Full Time

Part Time

Per Diem

Shift Preference:

When would you be available to start?:

Based on work history and experience, explain why you can do this job:

Were you previously employed by any program of Episcopal SeniorLife Communities:

Yes

No

If Yes, please give dates:

From:

To:

Do you have any relatives/friends that work at any program of Episcopal SeniorLife Communities:

Yes

No

If Yes, please give names:

Education

School

Name and Address

Last Year Attended

Diploma/Degree/Course of Study

Elementary

5	6	7	8

High School

1	2	3	4

College

1	2	3	4

Other Special Training

1	2	3	4

School of Nursing

1	2	3	4

Have you ever been convicted of any crime or violation of the law (other than a traffic violation):

Yes

No

If so, please explain each conviction:
Note: A prior criminal conviction is not
necessarily a bar to employment

Employment Experience

Please list all previous employers, starting with your current employer.

Employer:		Dates:	From:	To:
			(Month/Year)	(Month/Year)

Address:

Base Rate of Pay:

Per:

Phone:

Your Position:

Supervisor Name:

Reason for leaving:

Description of primary responsibilities:

Employer:		Dates:	From:	To:
			(Month/Year)	(Month/Year)

Address:

Base Rate of Pay:

Per:

Phone:

Your Position:

Supervisor Name:

Reason for leaving:

Description of primary responsibilities:

Employer:		Dates:	From:	To:
			(Month/Year)	(Month/Year)

Address:

Base Rate of Pay:

Per:

Phone:

Your Position:

Supervisor Name:

Reason for leaving:

Description of primary responsibilities:

Employer:		Dates:	From:	To:
			(Month/Year)	(Month/Year)

Address:

Base Rate of Pay:

Per:

Phone:

Your Position:

Supervisor Name:

Reason for leaving:

Description of primary responsibilities:

Employer:		Dates:	From:	To:
			(Month/Year)	(Month/Year)

Address:

Base Rate of Pay:

Per:

Phone:

Your Position:

Supervisor Name:

Reason for leaving:

Description of primary responsibilities:

Employer:		Dates:	From:	To:
			(Month/Year)	(Month/Year)

Address:

Base Rate of Pay:

Per:

Phone:

Your Position:

Supervisor Name:

Reason for leaving:

Description of primary responsibilities:

Professional References

Please do not list friends or family members.

Name	Address/Phone	# Years Known	Nature of Relationship

I authorize Episcopal SeniorLife Communities to verify the accuracy of the information provided on this application and to obtain reference information on my work experience. I hereby release Episcopal SeniorLife Communities, and any party supplying references, from any liability for an employment decision based on such information.

With regard to my current employer, Episcopal SeniorLife Communities:
contact my current employer.

May

May Not

I understand that failure to reveal any prior employer, or giving false or misleading information on any part of the application (or any other accompanying or required documents) can be the basis for refusal to hire, or grounds for termination from Episcopal SeniorLife Communities.

To sign this application, please type your name:

Date :

Please indicate any other last name by which you have been known:

Click here to submit this application.

Copyright © 2008 - 2010 Episcopal SeniorLife Communities. All rights reserved. | Web design and hosting by BizNetix. | Privacy Policy } Sitemap