* = Required Information
CNA RN LPN None
Yes No
Yes No
Yes No
Days Nights PM Any
In an emergency notify:
In an emergency notify (Secondary Person):
Military Record
Yes No

Please complete the following:

Yes No
Employment Desired
Yes No
Yes No
Yes No
Yes No
Yes No
Educational Background
High School
Yes No

Business / Trade School
Yes No

College
Yes No
Employment History



If there have been any gaps in your employment during the last five years, please provide details here:

References

Please list the persons who are not relatives whom we may contact as a reference.



I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations on this application or false statements made during the employment process may be considered sufficient cause for rejection of this application, or dismissal if I have been employed, no matter when discovered by Buckingham Pavilion Nursing Center Inc. (Company).

I hereby authorize the Buckingham Pavilion to thoroughly investigate my background, references, employment record, and other matters related to my suitability for employment, without giving me prior notice of such disclosure. In addition I hereby release the company and all former employers and third parties from any and all claims or liabilities arising out of or related to such investigation or disclosure.

I understand that nothing in this application, or conveyed during any interview, is intended to create a contract. If hired, I understand that my employment is at-will, and can be terminated by me or by the Buckingham Pavilion at any time, with or without notice, and with or without cause. If hired, I agree to follow all work rules, policies, and procedures related to work performance and conduct.

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