Quaker's Landing Employment Application

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Quaker's Landing Memory Care Community
101 Sterling Drive, Orchard Park, NY 14127
607-273-8072

APPLICATION FOR EMPLOYMENT

Name

First

Middle

Last

Social Security #

Address

City

State

Zip

Phone Number

Alternative

Referred By

Newspaper Advertisement
Personal Referral

Other

Are you currently employed?

Yes
No

If yes, why do you want to change your job?

May we contact your current employer?

Yes
No

If no, why not?

Employment Desired

Full Time
Part Time
Days
Evenings
Nights

Are you willing to work weekends?

Yes
No

If you work part time, what is your availability?

Position

Date you can start

Salary Desired

Please state why you should be considered for this position

Were you previously employed here?

Yes
No

If yes, where?

If yes, reason for leaving

Have you ever been convicted of a crime in New York state or any other jurisdiction?

Yes
No

Education and Training

TYPE	NAME/ADDRESS	MAJOR	GRADUATED/DEGREE
High School			Graduated? Yes No
College or University			Graduated? Yes No
College or University			Graduated? Yes No
Trade School			Graduated? Yes No
Other			Graduated? Yes No

List any other Education, Training, and Special Skills that you possess relating to this job:

Are you a U.S. citizen?

Yes
No

If no, do you have the legal right to remain and work in the
United States Permanently?

Yes
No

Professional Licensure or Registry

Type of Licensure or Registry

Licensure or Registry #

Date of Licensure or Registry

State Licensed or Registered in

Have you ever had an action against your license or registration?

Yes
No

If yes, date and reason

“We are an equal opportunity employment company. We are dedicated to a policy or non-discrimination in employment on any basis including race, creed, color, age, sex, religion, national origin, marital status, sexual orientation, disability or arrest record.”

List the names of 3 individuals who are not related to you and who can describe your work related skills.

References

NAME	ADDRESS	OCCUPATION	YEARS KNOWN	BUSINESS PHONE	HOME PHONE

Begin with your most present or most recent position. include past employment and all military and volunteer activities.

Employment Record

Name of Employer		Phone(required)
Address
Dates Employed From: To:	Title	Salary
Name and Title of Supervisor	May We Contact? Yes No	Reason For Leaving
Brief Description of Duties

Employment Record

Name of Employer		Phone(required)
Address
Dates Employed From: To:	Title	Salary
Name and Title of Supervisor	May We Contact? Yes No	Reason For Leaving
Brief Description of Duties

Employment Record

Name of Employer		Phone(required)
Address
Dates Employed From: To:	Title	Salary
Name and Title of Supervisor	May We Contact? Yes No	Reason For Leaving
Brief Description of Duties

Employment Record

Name of Employer		Phone(required)
Address
Dates Employed From: To:	Title	Salary
Name and Title of Supervisor	May We Contact? Yes No	Reason For Leaving
Brief Description of Duties

Click here for additional employment forms.

Are there any other experiences, skills, or qualifications, which you feel, would especially qualify you for work with our organization?

I certify that the information given to me in this application is true in all respects; and I agree that, if employed by Quaker's Landing Memory Care Community and any information is found to be false in any way, I may by subject dismissal without notice, if and when discovered.

I authorize the use of any information in the application to verify my statements; and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I also understand that a physical examination satisfactory to this Facility must be passed prior to employment.

Date

Signature(your name)
By writing your name you hereby authorize the use of the information provided.