PERSONAL DATA

Full Name (first, middle, last):    Home Phone: Cell Phone:

 Present Address (street address):

 Present Address (city, state, zip):

 Residence Addresses in last two years:

                        Street                                                City                                          State                            Zip

                       Street                                                City                                          State                            Zip

 Positions applied for:       Preferred Rate of Pay:

 Were you previously employed by us? If yes, when?

 List any friends or relatives employed by us.

 List any professional license numbers and types that  you have.

  EMERGENCY DATA

  In case of emergency, notify (include name, relationship, and phone):

 List any allergies.

EDUCATION    Name                      Course of Study        Years     Grad ?         Diploma / Degree

 High School                    

 College                           

 Other                              

 MILITARY SERVICE RECORD

  Were you in the armed forces ?  If yes, what branch?

  Dates of duty. Include From and To Dates.   Rank at Discharge.

  List duties in the service including special training.

 PERSONAL REFERENCES (NOT FORMER EMPLOYERS OR RELATIVES)

     Name and Occupation                          Relationship                               Phone number

 WHAT ATTRIBUTES/CHARACTERISTICS DO YOU HAVE THAT MAKE YOU FEEL YOU WOULD LIKE TO CARE AND/OR WORK FOR ELDERS?

 WORK HISTORY

 1. Company Name         City and State

     Contact Name                    Phone incl area code

     Position                             Employment dates (From - To)

 2. Company Name         City and State

     Contact Name                    Phone incl area code

     Position                             Employment dates (From - To)

3. Company Name         City and State

     Contact Name                    Phone incl area code

     Position                             Employment dates (From - To)

 4. Company Name         City and State

     Contact Name                    Phone incl area code

     Position                             Employment dates (From - To)

 Applicant's comments relative to above employment.

  Are there any other experiences, skills, or qualifications which you feel would especially qualify you for work with the company?

 THIS IS NOT A TEST ---     This is a questionnaire to aid Eden Retirement Center, Inc. when you accept a position of employment.  It is used only for scheduling purposes that will be close to ideal for both you and Eden.  Family, social, economical and personal needs are considered for scheduling only.

 Please answer the following with direct and honest responses:

1.  Insert 1, 2, 3 in order of preference:

  Shifts    7 AM to 3 PM          3 PM to 11 PM            11 PM to 7 AM         Anytime    

2.  Name which days of the week you are NOT AVAILABLE TO WORK. 

3.  Would you accept a work schedule that requires working every other weekend?

4.  Would you work every weekend?    

5.  Would you work overtime?  

6.  Can you be called to fill-in where needed?

7.  Do you prefer part time or full time?

8.  Have you worked in the nursing home environment before?

NOTE: APPLICATIONS WILL NOT BE CONSIDERED ACTIVE AFTER NINETY DAYS FROM DATE OF APPLICATION UNLESS THE APPLICANT APPEARS IN PERSON TO REAPPLY.

ALL APPLICANTS WILL BE CONSIDERED WITHOUT REGARD TO RACE, COLOR, AGE, RELIGION, SEX, NATIONAL ORIGIN, OR PHYSICAL HANDICAP. (SECTION 504)

Signature of Applicant

Date of Application