* If you answered yes, attach a page and explain. Include dates, places, charges, and results. Disclosure of information will not necessarily bar you from consideration for employment and will only be considered in relation to specific job requirements. Age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into consideration. Under federal regulations, however, conviction of resident/client abuse, neglect, or mistreatment or misappropriation of resident property will disqualify you from consideration for employment.

License/Certificate

Educational Attainment and Employment

High School

College

Graduate School

Business/Trade School

Other

Beginning with your present or most recent employment (regardless of length of time), list all periods of employment and unemployment including military service assignments and volunteer activities.