Woodlawn Care Center - Newport, NH
Pre-Employment Questionaire
Woodlawn Care Center
84 Pine Street
Newport NH 03773
(603) 863-1020 FAX (603) 863-2250

Woodlawn is an Equal Opportunity Employer

Application Date: *     *     *
Have you ever been employed with us before?        


High School:
Undergraduate College:
Graduate/ Professional:
Other (Specify):


RN Expiration          
LPN Expiration          
LNA Expiration          



Are You Currently Employed?        
If so, may we contact your current employer?        
When would you be available to begin work
if offered a position of employment?
If you are not a citizen of the U.S.,
do you have legal right to remain
permanently and work in the U.S.?
If you are under eighteen (18) years
old you are required to have working
papers. Do you have working papers?
Federal law established certain hour restrictions
for anyone under sixteen (16) years old.
Will these hour restrictions apply to you?

NOTE: If you used a maiden name or another name with previous employers,
please give us that name. Also, please list your current or last job first.

Current / Last Job:
Employed From:          
Employed To:          
May we Contact?        
Previous Job:
Employed From:          
Employed To:          
May we Contact?        
Previous Job:
Employed From:          
Employed To:          
May we Contact?        
Comments:Include explanation of any gaps in employment.

Do not use relatives as personal references

Reference 1:
Reference 2:
Reference 3:


Have you ever been convicted of a felony?        


Please read carefully before signing:
I confirm that all information contained on this form is accurate and true, that all statements here are subject to verification by Woodlawn Care Center and I release, indemnify and hold harmless Woodlawn Care Center from any and all liability, which might result from making a verification or investigation. I understand that this Pre-employment Questionnaire does not constitute an offer of employment.
Signature Date: *     *     *

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