Position Applying For:

Last Name:

First Name:

Street Address:

City:

State:

Zip Code:

Are you 18 or older?

Yes No

Maiden Name:

Telephone Number:

Cell Phone Number:

Have you ever worked here before? Yes No

Are you currently employed? Yes No

May we contact your employer? Yes No

Salary Desired:

$

Date Available to work:

Would you work any shift? Yes No

Would you work weekends? Yes No

Would you work holidays? Yes No

Shift preference:

6-2 2-10 10-6

How did you hear about Sunrise Manor?

Are you eligible for employment in this country? Yes No

Have you ever been convicted of any felony offense or a misdemeanor offense of abuse, neglect, or theft? Yes No

If yes, explain:

School Name(s)

Address

Curriculum

Years / Graduate / Degree

Type

Organization & State Issued

Date Issued

Long range occupational goals:

(Please list name, address, and phone number of previous employers with most recent first)

Job Title:

From:

To:

Immediate Supervisor:

Last Salary:

Phone #:

Employer Name:

Address:

Duties:

Reason for Leaving:

Job Title:

From:

To:

Immediate Supervisor:

Last Salary:

Phone #:

Employer Name:

Address:

Duties:

Reason for Leaving:

Job Title:

From:

To:

Immediate Supervisor:

Last Salary:

Phone #:

Employer Name:

Address:

Duties:

Reason for Leaving:

Name:

Phone #:

Address:

Name:

Phone #:

Address:

Name:

Phone #:

Address:

Share any additional information that you think would help us in considering your application for this position:

I affirm that everything is true and correct, and I acknowledge that I can be terminated at any time if it turns out that any information I supply is false. I affirm that I have a genuine intent and no other purposes in applying for a job with Sunrise Manor.

Sunrise Manor is an equal opportunity employer and does not discriminate in employment. No question on this application is used for the purpose of limiting or excluding an applicant's consideration for employment on a basis prohibited by local, state, or federal law.

I give Sunrise Manor the right to investigate all references and to secure additional information about me. I hereby release from liability Sunrise Manor and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I understand that if employed by Sunrise Manor, the employment is at will and may be terminated at any time by the employee or employer. No representatives of Sunrise Manor have the authority to make any assurance to the contrary.

Applicant's Signature: