Medicare 5 Star Rated Home
Call Today: (585)223-3633

6745 Pittsford-Palmyra Road, Fairport, New York 14450

Employment Form

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 Crest Manor, I agree to abide by its rules and regulations.
  3. Any misrepresentation or omission will also be cause for Crest Manor 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 Crest Manor and release Crest Manor 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 Crest Manor or an authorized agent thereof.

Crest Manor Living & 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.

Crest Manor Living & Rehabilitation Center, Inc. will make reasonable accommodations to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodations would impose an undue hardship or a significant risk of substantial harm.