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

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

Hourly Rate/Salary

Starting:

Ending:

Duties Performed

Employer #2

Name

Address

Telephone Number

Job Title

Supervisor

Reasons for Leaving

Dates Employed

From

Hourly Rate/Salary

Starting

Ending

Duties Performed

Employer #3

Name

Address

Telephone Number

Job Title

Supervisor

Reasons for Leaving

Dates Employed

From

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