Careers

*required FIELDS

Personal Information


Position


YesNo

YesNo

YesNo

YesNo

Holidays:YesNo
Weekends:YesNo
Oncall:YesNo
Varied Shifts:YesNo

YesNo


YesNo

YesNo
*Have you been convicted of a criminal offense within any state?
YesNo
Date:
Charges:
Location:
County:
State:

Education

High School


YesNo

College


YesNo

Advanced Degree/Trade School


YesNo

Employment History (List most recent job first)


State if you do not want us to contact any of the listed former or current employers and the reason you do not want each contacted:

Authorization for Release of Information

I hereby authorize the release to Cornwall Manor any and all information relative to my employment, including but not limited to dates of employment, attendance records, performance ratings, rates of pay and eligibility for re-employment. I authorize its release without penalty or liability.

*Please type your name below to indicate agreement:
*Date:

Licenses, Registrations, & Certifications

If licensed, registered, or certified:
Type:
State issued:
Date:
Number:

Type:
State issued:
Date:
Number:

Do you have a valid Driver's License?
YesNo
State issued:
Number:
Did you serve in the U.S. Armed Services?
YesNo
Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, skills, abilities, articles/books published, activities, foreign languages, accomplishments, professional/trade/ business/or civic activities and offices held, etc. (You may exclude all information indicative of age, sex, race, religion, color, national origin, handicap or disability, or any relationship with any labor organization.)

References (List three references who are not relatives or employers)
Name:
Occupation:
Phone: 
Email:
Name:
Occupation:
Phone:
Email:
Name:
Occupation:
Phone:
Email:

Completion

Carefully read the Cornwall Manor Mission Statement prior to answering the question and providing a signature below:

Organizational Mission

Cornwall Manor offers diversified and high quality housing, health care and related services for individuals to achieve a retirement and aging lifestyle they find fulfilling in a secure, caring and Christian environment.

*Can you work under the principles of our mission statement?
YesNo
*Please type your name below to indicate agreement:
*Date:
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