Employment Application

CONTACT INFORMATION

Name
Email
Address
Home Phone
Cell Phone
Position Applying For
Date Available
Acceptable rate of pay
Number of hours desired: Maximum
Number of hours desired: Minimum
Times you are NOT available to work – days/hours
Do you have a valid CT driver’s license?
Commercial Driver's License?
Are you legally eligible for employment in the United States? Verification will be required
Please list any Professional Licenses, Certifications, or Registrations currently held
Please list any additional qualifications relating to this position

EDUCATION

High School Name
Location
Date
Did you graduate?
College Name
Location
Date
What was your major?
Did you graduate?

PREVIOUS EMPLOYMENT

Company #1
Phone
Address
Supervisor's full name
Job description
Pay rate
Dates of employment
Reason for leaving
May we contact your previous supervisor for a reference?
Company #2
Phone
Address
Supervisor's full name
Job description
Pay rate
Dates of employment
Reason for leaving
May we contact your previous supervisor for a reference?
Company #3
Phone
Address
Supervisor's full name
Job description
Pay rate
Dates of employment
Reason for leaving
May we contact your previous supervisor for a reference?

REFERENCES

Please list 3 PROFESSIONAL references that can be contacted.

Reference #1 Full Name
Relationship
Company
Number of years known
Email
Phone
Reference #2 Full Name
Relationship
Company
Number of years known
Email
Phone
Reference #3 Full Name
Relationship
Company
Number of years known
Email
Phone

AGREEMENT

In completing and submitting this application, I understand and agree that: 1. All of the information provided by me in this application (or other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. Any misstatement or misleading of facts will be sufficient reason for immediate withdrawal of this application, or, in the event of employment, be cause for termination regardless of the timing or circumstances of discovery. 2. I give my consent to my previous employers and references to give information concerning my employment, character, ability, and/or experience to Meadowbrook Gardens (hereinafter referred to as “MBG”). 3. No question on this application has been answered in such a manner as to disclose my sex, race, color, religion, or national origin. 4. I understand that submission of an application does not guarantee employment. I further understand that should an offer of employment be extended by MBG that such employment is at will, for no specified duration and may be terminated by either MBG or myself at any time, with or without cause or notice. 5. If employed, I may be required to furnish proof of age by birth certificate. 6. If employed, MBG shall be entitled to receive reports concerning injury or illness from attending physicians and practitioners. 7. If employed, I agree to abide by all rules, regulations, policies and procedures set forth by MBG.

Signature
Date