Pre-Employment Questionaire

EMPLOYMENT

GALLERY

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

Woodlawn is an Equal Opportunity Employer

Application Date:

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First Name:

Middle Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Primary Phone:

Email:

Verify Email:

Position(s) Desired:

Have you ever been employed with us before?

Yes No

If Yes, When?

EDUCATION

High School:

Name & Address of School:

Course of Study:

Years Completed:

Diploma / Degree:

Undergraduate College:

Name & Address of School:

Course of Study:

Years Completed:

Diploma / Degree:

Graduate/ Professional:

Name & Address of School:

Course of Study:

Years Completed:

Diploma / Degree:

Other (Specify):

Name & Address of School:

Course of Study:

Years Completed:

Diploma / Degree:

PROFESSIONAL LICENSING INFORMATION

RN License #

RN Expiration

RN State

LPN License #

LPN Expiration

LPN State

LNA License #

LNA Expiration

LNA State

RELATED SKILLS

Skills

AVAILABILITY

Are You Currently Employed?

Yes No

If so, may we contact your current employer?

Yes No

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.?

Yes No

If you are under eighteen (18) years
old you are required to have working
papers. Do you have working papers?

Yes No

Federal law established certain hour restrictions
for anyone under sixteen (16) years old.
Will these hour restrictions apply to you?

Yes No

EMPLOYMENT RECORD

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:

Employer:

Address:

Telephone Number(s):

Starting/Ending Job Title:

Supervisor:

Employed From:

Employed To:

Start Salary:

End Salary:

Work Performed:

Reason for Leaving:

May we Contact?

Yes No

Previous Job:

Employer:

Address:

Telephone Number(s):

Starting/Ending Job Title:

Supervisor:

Employed From:

Employed To:

Start Salary:

End Salary:

Work Performed:

Reason for Leaving:

May we Contact?

Yes No

Previous Job:

Employer:

Address:

Telephone Number(s):

Starting/Ending Job Title:

Supervisor:

Employed From:

Employed To:

Start Salary:

End Salary:

Work Performed:

Reason for Leaving:

May we Contact?

Yes No

Comments:

Include explanation of any gaps in employment.

PERSONAL REFERENCES

Do not use relatives as personal references

Reference 1:

Name:

Occupation:

Address:

Phone Number:

Best Time to Call:

Years Known:

Reference 2:

Name:

Occupation:

Address:

Phone Number:

Best Time to Call:

Years Known:

Reference 3:

Name:

Occupation:

Address:

Phone Number:

Best Time to Call:

Years Known:

CRIMINAL RECORD

Have you ever been convicted of a felony?

Yes No

APPLICANT

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.

Electronic Signature of Applicant:

Signature Date:

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