Personal Information

If yes, provide employment dates:

Prior Work Experience

Current or Most Recent

Dates of Employment


Dates of Employment


Dates of Employment


High School


Trade School


Personal References

Reference 1

Reference 2

Reference 3


  1. The above information is complete and true to the best of knowledge.
  2. If employed by Eastside Nursing & Rehabilitation Center, I agree to abide by its rules and regulations.
  3. Any misrepresentation or omission will also be cause for Eastside Nursing & Rehabilitation Center 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 Eastside Nursing & Rehabilitation Center and release Eastside Nursing & Rehabilitation Center 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 Eastside Nursing & Rehabilitation Center or an authorized agent thereof.

Eastside Nursing & Rehabilitation Center, 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.

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