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Application of Employment

Wedgewood Estates of Mansfield, Senior Residential Community, is an Equal Opportunity Employer, committed to employing individuals without regard to race, color, age, sex, martial status, veteran status, religion, creed, national origin, ancestry, or handicap.

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Date of Application *

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Name: * This field is required

Social Security Number * This field is required

Drivers License No. * This field is required

Birthdate *

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Current Address

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Street: * This field is required

City: * This field is required

State: * This field is required

Zip: * This field is required

Country: * This field is required

Phone: * This field is required

Are you at least 18 years old?

A. Yes

B. No

If employed and you are under 18, can you furnish a work permit?

A. Yes

B. No

What type of employment are you interested on? *

Full-time

Part-time

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What position are you applying for? *

A. Day Shift Companions/Nurses (6a-6p) sometimes 6a-2p

B. Night Shirt Companions/Nurses (6p-6a) sometimes 4p-11p

C. Laundry/Housekeeping

D. Dietary

E. Maintenance

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Have you ever been employed by any other name? *

A. Yes

B. No

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If you answered yes please provide the name

Have you ever applied or been employed by Wedgewood Estates? *

A. Yes

B. No

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If yes, please provide the dates

Are you employed now and if so, may we contact your present employer? *

A. Yes

B. No

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Name: Person to contact

First Name:

Last Name:

Phone:

If we cannot inquire your present employer, please explain why:

Are you on layoff and subject to recall? *

A. Yes

B. No

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If employed, does your employment require you to continue working for your current employer, or restrict your activities after leaving your current employment, for any period of time? *

A. Yes

B. No

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If yes, until what date?

Are you prevented from becoming lawfully employed in this Country because of VISA or Immigration Status? *

A. Yes

B. No

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Name: In case of emergency, family physican.

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First Name: * This field is required

Last Name: * This field is required

Phone: * This field is required

Are you physically and mentally capable of performing the essential duties of the position for which you are applying? *

A. Yes

B. No

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If not, please explain:

Are you a veteran of the U.S. Military service? *

A. Yes

B. No

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If yes, what branch?

Have you ever been convicted of a crime, other than a minor traffic violation, within the last ten years? *

A. Yes

B. No

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If yes, describe:

Date you can start: *

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Salary Desired: * This field is required

Please list employment from previous four jobs then provide the start and end dates plus why you left previous employment. * This field is required

Please list the levels of education you have completed: * This field is required

Please provide three names (phone number and email address) of people no related to you that you have known for at least one year: * This field is required

Please list any community, religious, or social organizations of which you are a part of:

Please provide the following information that will be sent to a state-approved agency to verify background information: *

Name
Social Security Number
Date of Birth

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