Were you previously employed at Gurwin Center, Gurwin Fay J. Linder Residences, Long Term Home Health Care and/or The Gurwin Home Care Agency?
Yes No

If yes, specify position and date:

Criminal background checks are performed on all applicants for employment.

Have you ever been convicted of a misdemeanor or felony, excluding traffic violations? (Conviction record will not automatically make you ineligible for employment)
Yes No

If yes, describe in full:

I certify that the information I have provided to the foregoing questions is true and correct, and no attempt has been made to conceal information. I authorize my former employers, schools and personal references to provide any information they may have regarding me, whether or not it is on their records. I hereby release them and their company from all liability for divulging same. I understand that if any information given by me in this application, is found to be false or misleading, I will be subject to dismissal at anytime during the period of my employment. I also understand that a criminal background check may be conducted.

If employment is obtained under this application I will comply with all the rules and regulation of the Center. I agree to be responsible for all property and equipment issued to me the Gurwin facilities until returned by me and to pay for any property and equipment not returned. I agree to submit to physical examination and understand that my employment is contingent upon, a satisfactory medical evaluation. Further, I understand and agree that my employment is for no definite period of time and may, be terminated at any time, unless otherwise agreed to in writing. I also understand that no one has the authority to make any agreement concerning the terms and conditions of my employment unless the agreement is made in writing and signed by an authorized representative of the Gurwin facilities.