"*" indicates required fields Applications are accepted for posted positions onlySpecific Positions Applying For* Personal InformationLast Name First Name Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Cell PhoneMINIMAL REQUIREMENTS (upon request, you will be required to furnish documentation)Are you at atleast 18 years old?* Yes No Do you have a GED/HS Diploma?* Yes No Do you have a valid driver's license?* Yes No State* Upon employement, can you furnish documents in original form, which provide your identity and proof that you have the legal right to work in the United States of America?* Yes No REFERAL SOURCE (please list) Manor Website Internet Posting Employee Referral Newspaper other General InformationAre You Currently Employed* Yes No Have you interviewed for a position at The Manor before?* Yes No Have you ever been employed by the Manor?* Yes No Please list the approximate date of employement & yours previous position title:* BACKGROUND INFORMATION:Have you ever convicted of crime?*(Conviction will not necessary disqualify applicant from consideration for employment) Yes No List*DateOffenseDisposition of CaseEDUCATION / TRAININGHigh SchoolSchool NameCityYear of Graduation Add RemoveCollege / UniversitySchool NameCityYear of Graduation Add RemoveOther InstitutionSchool NameCityYear of Graduation Add RemoveSpecial certifications/training or other additional information: EMPLOYMENT HISTORYPlace of EmploymentCity/StateDates of EmploymentJob TitleReason for Leaving Add RemoveHave you ever been dismissed or ask to resign from a position?* Yes No May we contact your former employers?* Yes No May we contact your present employer?* Yes No REFERENCES*Minimum 2 of supervisory references; references should not include relatives):Reference Name# Yrs AcquaintedCompany (If Applicable)Relation to youPhone Add RemoveAPPLICANT STATEMENT*I certify that the information provided in this application is accurate. I understand that the withholding of information or the giving of false information on this application or my resume will result in a refusal to hire or in disciplinary action up to and including the termination of my employment. I understand and agree that if I am offered employment by The Manor, it will be for an indefinite term and on an at-will basis. This means that either I or The Manor may terminate the employment relationship at any time, with or without cause. I understand that this is an "at-will" relationship. I also understand that other terms and conditions of my employment will be governed by various policies and programs of The Manor, in writing and otherwise, and that those policies and programs may be changed from time to time by The Manor at its discretion without affecting the "at-will" nature of employment. I understand that neither this document, nor any offer of employment from the employer constitute, an employment contract unless a specific document to that effect is executed by the employer and employee in writing. I hereby grant permission to any person, firm, or corporation to release to The Manor, or its representative my and all information regarding my past work or employment and my background. I hereby release The Manor and the above referenced organizations, referenced persons and employers from all claims, liability and damages that may result from furnishing the information to you. I waive any and all claims I might have with respect to the providing of such information. Furthermore, in connection with my application for employment with you, I understand that a consumer report may be requested that may include information as to my character, along with reasons for termination of past employment from previous employers. I understand that you may be requesting information concerning my motor vehicle operation history and criminal history from various states, private and insurance sources along with other public records available. This report may also include credit information. I have read the above prior to signing this application.Signature*Date MM slash DD slash YYYY Human Rescource Department The Manor P.O. Box 98 Jonesville, Michigan 49250 Fax: (517) 849-2880
