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Employment Form

Personal Information

If yes, provide employment dates:

Prior Work Experience

Current or Most Recent

Dates of Employment

Prior

Dates of Employment

Prior

Dates of Employment

Education

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College/University

Trade School

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Personal References

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APPLICANT'S STATEMENT:

  1. The above information is complete and true to the best of knowledge.
  2. If employed by LeRoy Village Green RHCF, I agree to abide by its rules and regulations.
  3. Any misrepresentation or omission will also be cause for CLeRoy Village Green RHCF refusing to hire me.
  4. I hereby authorize all persons, companies and corporations to release and provide any and all information regarding my employment to LeRoy Village Green and release LeRoy Village Green from all liabilities for issuing this information.
  5. I agree as a condition of my employment that I must take and pass a physical examination and drug test at no personal expense to me. I also agree that the examining physician may disclose findings of that examination to LeRoy Village Green or an authorized agent thereof.

LeRoy Village Green RHCF, Inc. is an Equal Opportunity Employer and complies fully with Federal and New York State laws prohibiting discrimination in employment because of sex, age, race, color, creed, national origin, religion, marital status, availability for military services, disability, sexual orientation or arrest/conviction record.

LeRoy Village Green RHCF, Inc. will make reasonable accommodations to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodations would impose an undue hardship or a significant risk of substantial harm.