Palms of Punta Gorda
Employment Application
Name *
Last, First, Middle, Maiden
Social Security Number *
Date of Application *
Present Address *
Telephone *
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.
Shifts Available *
How many hours can you work weekly? *
Employment desired *
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.
Educational History *
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?
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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