Careers Form

* = Required Information

First Name *

Last Name *

Middle Name

Email Address *

Date

Street Address*

City*

State

Zip Code*

Home Phone

Business Phone

Emergency Contact (Person not living with you)*

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Yes

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Newspaper Ad

Agency Employee

Are you willing to work: Evenings?

Yes

Are you willing to work: Weekends?

Yes

Position Applying For

College

School Name / Degree

Location of School

Course of Study

Years of Study

Vo-Tech or Trade

School Name / Degree

Location of School

Course of Study

Years of Study

High School

Location of School

Course of Study

Years of Study

Other

High School

Location of School

Course of Study

Years of Study

List the last five years employment history, starting with the most recent employer.

Company Name

Telephone

Address

City

State

Zip Code

Job Title

Describe your work

Dates of Employment

From

Starting Pay

Reason For Leaving

Company Name

Telephone

Address

City

State

Zip Code

Job Title

Describe your work

Dates of Employment

From

Starting Pay

Reason For Leaving

Company Name

Telephone

Address

City

State

Zip Code

Job Title

Describe your work

Dates of Employment

From

Starting Pay

Reason For Leaving

Was your last name different from your present name during the above listed jobs?

Yes

What was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Persons who can furnish information about job performance

Name

Telephone

Address

Fax

Name

Telephone

Address

Fax

Name

Telephone

Address

Fax

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment.

Describe in full

Are you capable of performing the job set forth in the job description?

Yes

Which job requirement can you not meet?

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Date

Name*

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Date

Date of Application

Previous Employer

Contact Person

Address

Phone

Fax

I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

Applicant Name

Date

To be completed by previous employer:

Date of employment

From

Position Held

Would you rehire this individual?

Yes

Responsibilities

Rate of Pay (weekly/biweekly/salary)

Reason for Leaving

Additional comments (training/skills)

Reference check performed by

To Whom It May Concern:

To be filled out by applicant:

Applicant Name

Date of Application

Previous Employer

Contact Person

Address

Phone

Fax

Applicant Name

Date

To be completed by previous employer:

Date of employment

From

Position Held

Would you rehire this individual?

Yes

Responsibilities

Rate of Pay (weekly/biweekly/salary)

Reason for Leaving

Additional comments (training/skills)

Reference check performed by

Employee Name

Current Address

Home Phone

Cell Phone

Next of Kin

Phone

Relationship

Address

In case of emergency, please contact

Name

Phone

Relationship

Address

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