1. Last Name*

2. First Name*

3. Middle Name*

4. Date of Birth (if under 18)*

5. Street Address*

6. City*

7. State*

8. Zip Code*

9. Phone*

10. Social Security Number*

11. Are you Authorized to work in the U.S.?

Yes No

12. Category of Work

Full Time Part Time Temporary

13. Date Available

14. What Days can you work?

M T W TH F SA SU

15. What hours can you work?

16. Have you ever applied with us before?

No Yes

If yes-when?

17. Have you ever worked for us before?

No Yes

If yes-when?

EDUCATION

18. Check grade Completed

7th 8th 9th 10th 11th 12th

19. Last High School Attended

20. Major Course of Study

21. College, Technical, Trade or Other

22. Name of School

23. Major Course of Study

24. Degree or Diploma Granted

SKILLS

28. Please check areas in which you hav experience or training:

28. Please check areas in which you have experience or training:

Data Processing Typewriter Switchboard Medical Technology Other

If other, explain

WORK HISTORY

29. Please provide the names of your most recent employers complete with Company Names and Address, Dates of Employment and Positions of Duties.

29answer

PERSONAL REFERENCES

30. Please provide Names, Addresses and Phone Numbers.

30. Please provide Names, Addresses, and Phone Numbers.

31. Excluding traffic violations, have you ever been convicted of a crime?

31. Exculding traffic violations, have you ever been convicted of a crime?

Yes No

32. If yes, describe in full...

33. Do you accept the possibility of working weekends, holidays or rotation shifts?

33. Do you accept the possibility of working weekends, holidays or rotation shifts?

Yes No

34. Do you understand that, due to the services we provide, an exceptional record of attendance, promptness and dependability is required of all employees?

34. Do you understand that, due to the services we provide, an exceptional record of attendance, promptness and dependability is required of all employees?

Yes No

35. Do you understand that employment is contingent upon satisfactory education, prior employments and reference verification?

35. Do you understand the employment is contingent upon satisfactory education, prior employments and reference verification?

Yes No

36. Do you further understand that willfully making false statements on this application will be sufficent cause for discharge?

36. Do you further understand that willfully making false statements on this application will be sufficent cause for discharge?

Yes No

37. Do you understand that we are an Equal Opportunity Employer as outlined in federal and New York State laws against discrimination? Also, that no qualified person with disabilities shall be subject to discrimination in our employment in our process?

37. Do you understand that we are an Equal Opportunity Employer as outlined in federal and New York State laws against desrimination? Also, that no qualified person with disabilities shall be subject to discrimnination in our employment in our process?

Yes No

38. Do you understand that any offer of employment is contingent upon your providing proof of U.S. Citizenship to work in the U.S.?

38. Do you understand that any offer of employment is contigent upon your providing proof of U.S. Citizenship or authoritization to work in the U.S.?

Yes No

39. We are committed to provide "loving care" to all clients and we are required that all employees share this commitment. If employed by us, can you share this commitment?

39. We are committed to providing "loving care" to all clients and we are required that all employeess share this commitment. If employed by us, can you share this commitment?

Yes No

Companionship:

Yes No

We are an Equal Opportunity Employer

I understand that all information concerning residents, clients, their dooctors, and fellow employees is strictly confidential. I agree to honor the policy which states concerns corporate and employee business is confidential . I hereby affirm the informa