Application for Employment

Applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender, or age.

Applying to

Skilled Nursing/Kingsway Arms

Assisted Living/Kingsway Manor

Independent Living

Home Care

Kids Center

Resume Upload: (pdf,doc)

Personal Information

Pre-employment drug testing is required.

Name: (first name & last name)

Address: (Street, City, State, Zipcode)

Telephone: (xxx-xxx-xxxx)

Cell: (xxx-xxx-xxxx)

If under 18 years of age, do you have a work permit?

Yes

No

Are you a U.S. citizen?

Yes

No

Do you have the legal right to remain permanently and work in the U.S.?

Yes

No

Do you currently have charges pending or have you ever been convicted of a crime, felony or misdemeanor? (You must answer YES if you hav charges pending or have been convicted of any crime in New York or any other State within the USA or any foreign country.)

Yes

No

Please give date(s) and nature of offense(s):

Availability

Position Desired:

Date available for work: (mm/dd/yyyy)

Type

Full Time

Part Time

Per Diem

Full or Part Time

Days and hours/shift available:

Salary requirements:

Registered/Certified?:

Have you ever worked and/or been certified or licensed under another name?

Yes

No

If yes, what name?

Have you ever worked on the Kingsway campus before?

Yes

No

When?:

Which Facility?:

Which Department?:

Reason for leaving:

Referred by

Newspaper Ad

Gazette

Times Union

Job Fair

Internet Website

Personal Referral

Employee Referral

Name of Employee:

Other

Please List:

Education

Last School Attended:

Vocational or Trade Training:

Are there any limitations that would prohibit you from performing the job you are applying for?

Yes

No

Employment History

List all current and past employment experiences, beginning with the most recent. Use the Job Notes section at the end if necessary.

Item 1 (Current or Most Recent)

From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

Current or most recent employer:

Address: (Street, City, State, Zipcode)

Phone: (xxx-xxx-xxxx)

Supervisor's Name:

Job Title:

Starting Salary:

Ending Salary:

Briefly describe your job duties and work experience:

Reason for leaving:

Item 2

From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

Current or most recent employer:

Address: (Street, City, State, Zipcode)

Phone: (xxx-xxx-xxxx)

Supervisor's Name:

Job Title:

Starting Salary:

Ending Salary:

Briefly describe your job duties and work experience:

Reason for leaving:

Item 3

From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

Current or most recent employer:

Address: (Street, City, State, Zipcode)

Phone: (xxx-xxx-xxxx)

Supervisor's Name:

Job Title:

Starting Salary:

Ending Salary:

Briefly describe your job duties and work experience:

Reason for leaving:

Item 4

From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

Current or most recent employer:

Address: (Street, City, State, Zipcode)

Phone: (xxx-xxx-xxxx)

Supervisor's Name:

Job Title:

Starting Salary:

Ending Salary:

Briefly describe your job duties and work experience:

Reason for leaving:

Job Notes/Additional Information

May we contact your present employer at this time?

Yes

No

Applicant Statement

I understand that any employment by this Company will be on a six (6) month introductory basis. If employed by the Company, I agree to abide by its rules and regulations. Further, I understand that my employment can be terminated any time by either party. I herby certify that all entries on the application, are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the Company. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact any reference, former employers, and educational institutions listed regarding application. I further authorize the Company to rely upon and use, as it sees fit, any information received from such contacts.

I understand that Kingsway Community is a drug-free work place and that I will be subject to the Company's pre-employment and random drug testing program.

I have read and understand the above statement.