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Application for Employment

Full Time Part Time Temporary
Website (specify)
School (specify)
Newspaper (specify)
Agency (specify)
Other (specify)



High School

Yes No

College or University

Yes No

Nursing School

Yes No

Vocational, Business or Technical School

Yes No


Yes No

Work Experience

Including U.S. Military Service involving skills and training helpful in the Job for which you are applying.

List names and addresses of present and former employers beginning with the most recent.

Current Employer


Previous Employer 1


Previous Employer 2


Additional Information

Occasionally the format of an application makes it difficult for an individual to adequately summarize his/her complete background. To assist us in evaluating your application, use the space below to summarize any additional information necessary to describe your full qualifications.

Yes No

Medical, Technical and Professional Applicants

Company Questionnaire

Government agencies at times require periodic reports on the sex, ethnicity, disability, veteran and other protected status of applicants. This data is for analysis and possible affirmative action only. SUBMISSION OF THIS INFORMATION IS VOLUNTARY


I clearly understand, agree to, and accept the foregoing as a condition of hire.

In submitting this application, I also understand that false statements or omissions may disqualify me for employment or cause my subsequent dismissal. I authorize this organization to investigate all statements on this application including my employment record.

I certify that all statements I have made on this application are true and complete to the best of my knowledge; I have withheld nothing that would, if disclosed, affect this application unfavorably.

I understand that this employment application and any other Company documents or manuals do not constitute contracts of the employment, and any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee; any individual who is hired may voluntarily leave employment upon prior notice, and may be terminated by the employer at any time for any reason.

I hereby authorize my previous schools, employers and personal references permission to furnish Pine Haven Care Center with the facts and opinions as to my job performance and capabilities as ad employee, including employment data from my personnel file. I further release past schools, employers and all persons whomever from any damage because of furnishing said information.

By submitting this application you acknowledge that you have read the above statements and understand them.