Personal Information

Last Name: First Name: Address: Telephone #:
Posistion applied for: Location:

Are you prevented from lawfully becoming employed in this Country because of Visa or Immigration status? (Proof of Citizenship or immigration status will be required upon Employment) Yes No

Have you been convicted of a felony or misdemeanor within the past 7 years? Do you currently have any felony or misdemeanor charges pending? (Conviction will not necessarily disqualify you from employment.) Yes No If yes please explain in the space below:

Did you graduate from high school or obtain a G.E.D.? Yes No below list name and address of school and list highest level of education and honors also any degrees and professional registrations, certifications and/or licenses.:

Do you take transcription from a dictaphone? Yes No
Specify estimated words per minute for Typing and Shorthand:

Employment History

List most recent job first.


Company Name: Company Address: name of Supervisor: Telephone #:
Date Started: Date Ended: Rate of Pay at Start: Rate of Pay at End:
State your job title and describe your work:

Reason for Leaving:




Company Name: Company Address: name of Supervisor: Telephone #:
Date Started: Date Ended: Rate of Pay at Start: Rate of Pay at End:
State your job title and describe your work:

Reason for Leaving:




Company Name: Company Address: name of Supervisor: Telephone #:
Date Started: Date Ended: Rate of Pay at Start: Rate of Pay at End:
State your job title and describe your work:

Reason for Leaving:

May we contact your current employer for a reference? Yes No

References

Name: Address: Occupation: Telephone #: Number of Years Known:


Name: Address: Occupation: Telephone #: Number of Years Known:


Name: Address: Occupation: Telephone #: Number of Years Known:

I hereby apply to Birch Tree Communities, Inc. for employment, and if accepted, I agree to keep all rules and regulations and perform all duties assigned to me to the best of my ability according to the prescribed philosophy of Birch and to give at least two weeks’ written notice when resigning. I certify that all answers to the questions in this application are true and I further understand that any false statement in this application will be sufficient grounds for rejection of the application or termination of employment without notice at any time hereafter. I authorize all previous employers to furnish Birch my record, reason for leaving, and all information they may have concerning me, and I hereby release them and Birch from all liability for any damage whatsoever arising therefrom. I also authorize investigation of all statements in this application. I authorize Birch to make all necessary and appropriate investigations to verify the information contained herein unless otherwise specified. Further, I understand and agree that my employment is for no definite period, and may, regardless of the date of payment of my wages and salary, be terminated at any time without previous notice.
Agree Disagree