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Employment Application

Applicants will receive consideration without discrimination because of race, creed, color, sex, age, national origin, disability, religion, marital status, sexual orientation, status with regard to public assistance, military/veterans status or any other protected classes as defined by law.

Personal Information

(xxx-xxx-xxxx) (xxx-xxx-xxxx) (xxx@xxx.xxx)

Job Information

Proof of citizenship or Immigration status will be required upon request.

Are you available to work...
 Full Time (indicate shift)      
 Part Time (indicate shift)      
 Temporary (list dates)   (mm/dd/yy) (mm/dd/yy)



Employment History

Most Recent Employer
Employed (mm/dd/yy)

Second Most Recent Employer

Employed (mm/dd/yy)

Third Most Recent Employer

Employed (mm/dd/yy)

Equal Opportunity, Affirmative Action Voluntary Self Identification Form

(This information will not be retained with your employment application)
Tealwood Senior Care is an Equal Opportunity and Affirmative Action Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program. New Hires are invited to participate in the Affirmative Action Program by reporting their race, gender, veteran status and disability status. In extending this invitation you are also advised that: (a) employees are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary data required for our Equal Opportunity Reporting and Affirmative Action Program. Refusal to provide this information will have no bearing on your employment status and will not subject you in any adverse treatment.
(separate multiple positions with commas)
- A person having origins in any of the original peoples of Europe, North America and the Middle East.
- All persons of Cuban, Mexican, Puerto Rican, South or Central American, or any other Spanish culture or origin regardless of race.
- A person having origins in any of the black racial groups of Africa.
- A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
- All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.
- A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
- All persons who identify with more than one of the above races.
Veteran Status:
Are you a Veteran?
Disability Status:
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
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