Foulkeways at Gwynedd - A Continuing Care Retirement Community

PERSONAL DATA:


Name
Address
City
State
Zip Code
Phone Number
Email Address

Position Desired

Full Time

Part Time

Temporary

Salary Desired

Available to Start Work

Applicants must be at least 16 years of age. Do you meet this requirement?
Yes No

______________________________________

EDUCATION:


High School
Address
City
State
Major Course or Subject

Last Year Completed


College
Address
City
State
Major Course or Subject

Last Year Completed


Other
Address
City
State
Major Course or Subject

Last Year Completed

______________________________________

EMPLOYMENT RECORD:


Company Name
Address
City
State
Zip Code
Phone Number
Supervisor's Name

Employment Period
From MM/YY	To MM/YY

Salary
Start	Finish

Position and Duties

Reason for Leaving


Company Name
Address
City
State
Zip Code
Phone Number
Supervisor's Name

Employment Period
From MM/YY	To MM/YY

Salary
Start	Finish

Position and Duties

Reason for Leaving


Company Name
Address
City
State
Zip Code
Phone Number
Supervisor's Name

Employment Period
From MM/YY	To MM/YY

Salary
Start	Finish

Position and Duties

Reason for Leaving

______________________________________

GENERAL INFORMATION:

Are you legally authorized to work indefinitely in the United States?
Yes No

Have you ever been convicted of or had a history of violent crimes?
Yes No

Have you ever been dismissed from employment due to abuse of
clients or residents?
Yes No

Have you ever been convicted of any felony; or misdemeanor
including but not limited to larceny, embezzlement, drawing
or passing bad checks, forgery, or other similar crime
involving a breach of trust or the unlawful taking or
withholding of property belonging to another? (If you
have please answer "Yes"regardless of the degree of the
crime or its technical name.)
Yes No

Have you ever applied for employment with this company?
Yes No
If Yes, when

Have you ever been employed by Foulkeways?
Yes No

Dates of Employment
From MM/YY	To MM/YY

How did you find out about this position?
Newspaper Ad
Walk-in

Present Employee:

Other

Are you related to anyone at Foulkeways?
Yes No
If Yes, give name Department

Have you been excluded or prohibited, because of fraudulent
actions or default on student loans, from participating in any
government healthcare benefits program including but not
limited to the Medicare and Medicaid Programs?
Yes No

Answer the following questions only if driving a vehicle is a
requirement of the job applied for.

Do you have a valid driver's license?
Yes No

Do you own or have access to an automobile?
Yes No

______________________________________

HEALTH CENTER APPLICANT INFORMATION:

Shift Preference

7-3

3-11

11-7

License / Certificate Number
State

______________________________________

ALL APPLICANTS:

In addition to the above information, please indicate
any other qualifications you feel you have for the
position desired.

I affirm that the forgoing answers are true and complete
and I understand that if I am employed any false statements
and/or omissions herein may be considered sufficient cause
for dismissal.I hereby authorize you to make such inquiries
concerning the information supplied as you in your
discretion deem necessary, including a criminal history
check. Anyone mentioned herein is authorized to furnish
you with information in connection with this application
for employment.