- -
- -

If you are hired you will be required, within three days, to show proof of identity and authorization for employment in the United States. You will also be required to sign an I-9 Form, verifying, under oath, your employment authorization.


Starting with your most recent job; list all previous employers, including self-employment, summer and part-time jobs.


- -
- -




Please provide three Business References. No friends/family please 



- -


- -


- -



If you have any questions regarding this statement, please ask them of an employment interviewer before signing.

It is my understanding that Mary Wade will make a thorough investigation which will include a verification of my entire work history, and the verification of all data given in this application. I authorize such an investigation and the giving and receiving of any information by the Home. I am aware that I have a right to make a written request as to the nature and scope of this investigation. I release from liability any person giving or receiving such information.

In the event of my employment by Mary Wade, I will comply with all rules and regulations as set forth in the Home’s policy manual or the communication distributed by the Home to all employees. I understand that if I am hired, my employment with the Home will be "at will" and may be terminated by the Home or me at any time for any reason or for no reason. I understand that no documents or statements of the Home will constitute a contract or employment that in any way limits the Home’s rights to terminate my employment “at will.” I further understand that the “at will” nature of my employment cannot be changed except by a formal written contract signed by the Administrator of the Home.

I certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers, and that the responses given are true, complete and accurate to the best of my knowledge and are made in good faith. Without limiting the “at will” status of my employment if I am hired, I understand that if any of the statements on this application are untrue my employment will be terminated immediately.

I understand that Federal law prohibits the Home from hiring or retaining an employee who has been found guilty of patient abuse, neglect, or mistreatment by a court of law or who has had an adverse finding entered against him/her in the nurse’s aide registry. If it is discovered, subsequent to hire, that I have been untruthful about my history of patient abuse, neglect, or mistreatment, I will be subject to immediate discharge.

I authorize all the educators, agencies and employers listed in this application to furnish the Home with information regarding my education, employment history, or any other matter related to my application for employment with the Home.

I understand that this is an application for employment, and that no employment contract is being offered. I further understand that if employed, such employment is for no definite period of time and the Home can change wages, benefits, and conditions of employment at any time.

I have read and understand the above:



To enable the Home to meet government reporting regulations and to maintain an Affirmative Action Plan, applicants are requested to complete this personal data sheet.

INFORMATION WILL BE USED FOR GOVERNMENT REPORTING PURPOSES AND WILL BE DETACHED AND KEPT SEPARATE FROM JOB APPLICATION. This information will not be used as selection criteria and will be treated as personal and confidential. Your decision or refusal to provide the requested information will not subject you to any adverse treatment. Your voluntary cooperation will be appreciated.

If any of these definitions apply to you, please check off the appropriate box or boxes to be considered under our Affirmative Action Plan.

I qualify as a Special Disabled Veteran because I am:

A veteran who is entitled to compensation (or who, but for receipt of military retirement pay, would be entitled to compensation) under laws administered By the Veteran’s Administration for a disability:

I qualify as a Veteran of the Vietnam Era because I am a person who served more than 180 days of active military, naval, or air service, any part of which was during the period of August 5, 1964 through May 7, 1975