Job Application

Maple Ridge Manor Assisted Living and Memory Care, INC. (sometimes referred to herein as Maple Ridge Manor is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability genetic information, height, weight, marital or veteran status or any other protected status in accordance with the requirements of applicable local, state, and federal laws. Maple Ridge Manor also provides reasonable accommodation for individuals with disabilities in accordance with applicable laws.

    General

    First Name

    Middle Name

    Last Name

    Street Address

    Address City

    ZIP Code

    Home Phone

    Cell Phone

    Work Phone

    Email

    Were you previously employed by Maple Ridge Manor?

    If yes, when?

    Date of Separation:

    If no, how did you hear about us?

    Are you currently authorized to be lawfully employed in the United States? (Proof of eligibility will be required upon employment)

    Will you now or at any time in the future require our sponsorship for an employment visa or employment-based permanent resident status?

    Have you been convicted of, pled guilty to, or pled no contest to a felony or is there a felony charge presently pending against you (do not include arrests, expunged and/or sealed convictions)? Even if the answer is “Yes”, it will not necessarily disqualify you for employment. However, if the answer is “Yes”, provide the crime, approximate date, and state and county of court action.

    Have you entered into any form of restrictive covenant (non-compete agreement, non-solicitation agreement, confidentiality agreement, etc.) with any past or present employer, person or entity, which would prohibit or interfere with your ability to be employed by Maple Ridge Manor or to fully perform the functions of the position for which you are applying?

    If “Yes,” you may be required to furnish a copy of such agreement to be considered for employment.

    Are you at least age 18?y

    U.S. Military service?

    Branch/Rank:

    Description of military duties/List any special skills or training that may qualify you for employment:

    Position applying for:

    Date available to begin work:

    May we contact your present employer?

    What hours can you work:

    What days can you work?


    Education

    High School or Equivalent

    Name

    Last Date Attended

    Course of Study

    Graduated

    Degree, Diploma, or Certificate and when (to be)

    College

    Name

    Last Date Attended

    Course of Study

    Graduated

    Degree, Diploma, or Certificate and when (to be)

    Trade, Business or Graduate School

    Name

    Last Date Attended

    Course of Study

    Graduated

    Degree, Diploma, or Certificate and when (to be)

    Certifications

    Name

    Last Date Attended

    Course of Study

    Graduated

    Degree, Diploma, or Certificate and when (to be)

    Training

    Additional Training Courses

    Professional Certifications or Licenses

    Special Skills



    Employment History
    Include all employment (and self-employment), starting with your current or most recent employment. If you were unemployed for any time between any of the jobs listed below, indicate the dates of each period of unemployment and the reason.

    Employer #1

    Name

    Address

    Telephone Number

    Job Title

    Supervisor

    Reasons for Leaving

    Dates Employed

    From

    To

    Hourly Rate/Salary

    Starting:

    Ending:

    Duties Performed

    Employer #2

    Name

    Address

    Telephone Number

    Job Title

    Supervisor

    Reasons for Leaving

    Dates Employed

    From

    To

    Hourly Rate/Salary

    Starting

    Ending

    Duties Performed

    Employer #3

    Name

    Address

    Telephone Number

    Job Title

    Supervisor

    Reasons for Leaving

    Dates Employed

    From

    To

    Hourly Rate/Salary

    Starting

    Ending

    Duties Performed





    References
    List the name, address and telephone number of references not related to you and by who you are/were not employed, whom you have known at least three years.

    Reference #1

    Name

    Address

    Telephone Number

    Reference #2

    Name

    Address

    Telephone Number

    Reference #3

    Name

    Address

    Telephone Number

    Reference #4

    Name

    Address

    Telephone Number

    Describe any other special training or qualifications relevant to the position for which you are applying

    Attach Resume