Thornapple Manor Application for Employment

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Name Name * First Middle Last
Maiden Name(s) and or Other Last Names Used
Phone Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email *
Current Address Current Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth (D.O.B.) Date of Birth (D.O.B.) * / MM / DD YYYY

This information is used to conduct a criminal background check.
Gender

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Race

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Date Available Date Available * / MM / DD YYYY
Position Applying For: *

Position Applying For: Administration Certified Nursing Assistant Nurse Rehabilitation Life Enrichment Housekeeping CNA Class Dietary Other
Rate of Pay Expected: $_per hour
License or Certificate # (if applicable)
Shift Preferred

Shift Preferred First Second Third Flexible for Any Open Shift
Are you willing to work weekends, holidays and rotating shifts? *
Explain any limitations on Hours / Days:
Have you worked for us before? *
If yes, what year(s)?
List any friends or relatives working for us:
Do you have any skills or experiences which you feel would especially qualify you as a candidate?
If Yes, please describe:
Have you ever been convicted of a crime? *
If yes, then explain the nature of the conviction:
Are there any felony charges pending against you now? *
If yes, then describe:
Have you ever been debarred, suspended or otherwise ineligible from Medicare, Medicaid, or any other state or federal program for fraud? *