All fields are required. If you have no answer for a field, you must put the word 'none' in
that field. No field can be left blank.

*Position(s) applying for

*Full Name (First, Middle, Last)

*Social Security Number

*Street Address (no PO Box)

*City    *State Abbr.    *Zip Code 

*Daytime Phone with Area Code

*Evening Phone with Area Code

*Alternate or Cell Phone

*Email Address

*Have you ever been employed by Meadows before? YES   NO

If yes, give dates and positions:

*Date you are available to begin work

*Type of employment desired (check all that apply)

Full Time         Part Time         PRN          Weekend     

Days                Evenings          Nights       Holidays

Sun    Mon     Tues     Wed     Thurs     Fri     Sat

*Do you have reliable transportation? YES   NO

*Have you ever been convicted of a felony? YES   NO

If yes, please explain:

All fields are required. If you have no answer for a field, you must put the word 'none' in that field. No field can be left blank.

EDUCATION

*Are you currently attending school/college? YES   NO

*High School *Years Completed

Other Years Completed

*Certified Nurse Aide/Orderly in Illinois? YES   NO

*Other Licenses or Certificates?

*Expiration Date

EMPLOYMENT HISTORY
Please provide the following information for your past FOUR (4) employers and assignments
beginning with the most recent.
All fields are required. If you have no answer for a field, you must put the word 'none' in that
field. No field can be left blank.

1. (If no previous employment, put a the word 'none' in each field.)

*Job Title *Supervisor

* Employer

*Street Address (no PO Box)

*City    *State Abbr.    *Zip Code 

*Phone with Area Code

*May we contact? YES    NO

*Date Hired      *Date Terminated  

*Starting Salary      *Final Salary

*Reason for Leaving:

2. (If no previous employment, put a the word 'none' in each field.)

*Job Title *Supervisor

* Employer

*Street Address (no PO Box)

*City    *State Abbr.    *Zip Code 

*Phone with Area Code

*May we contact? YES    NO

*Date Hired      *Date Terminated  

*Starting Salary      *Final Salary

*Reason for Leaving:

3. (If no previous employment, put a the word 'none' in each field.)

*Job Title *Supervisor

* Employer

*Street Address (no PO Box)

*City    *State Abbr.    *Zip Code 

*Phone with Area Code

*May we contact? YES    NO

*Date Hired      *Date Terminated  

*Starting Salary      *Final Salary

*Reason for Leaving:

4. (If no previous employment, put a the word 'none' in each field.)

*Job Title *Supervisor

* Employer

*Street Address (no PO Box)

*City    *State Abbr.    *Zip Code 

*Phone with Area Code

*May we contact? YES    NO

*Date Hired      *Date Terminated  

*Starting Salary      *Final Salary

*Reason for Leaving:

REFERENCES
Please provide three (3).

1.

*Name     *Year Known

*Phone with Area Code

2.

*Name     *Year Known

*Phone with Area Code

3.

*Name     *Year Known

*Phone with Area Code

DO NOT SUBMIT UNTIL YOU HAVE READ THE STATEMENT ABOVE.

* By this check box and by submitting this on-line application form, I certify that I have read,
fully understand and accept all terms of the above Applicant Statement.