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Palms of Longwood
Last, First, Middle, Maiden
Social Security Number
Date of Application
Date of Birth
The Age Discrimination in Employment Act prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Position applied for
How did you learn of this opening?
Please be specific.
How many hours can you work weekly?
FULL or PART-TIME
Have you ever worked for this company before?
If yes to previous question, please state when, who the supervisor was and your reason for leaving.
Please list all educational history, including a list of schools attended (name + address), # of years completed, and any major/degree.
Do you have a QMAP certification?
If so, when did you complete the class?
Have you ever been convicted of a felony?
If yes, explain in detail. *A conviction record will not necessarily be a bar to employment, and factors such as age and time of the offense, the seriousness and nature of the violation, and the applicant's rehabilitation will be considered in the hiring decision. The applicant is responsible for providing final disposition paperwork.
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