Careers Form

* = Required Information

Employment Requirements

EMPLOYMENT APPLICATION
RESUME
LICENSE COPY/VERIFICATION
DIPLOMA/DEGREE/TRANSCRIPT
SOCIAL SECURITY CARD
CPR CARD
DRIVER’S LICENSE
AUTO INSURANCE
BACKGROUND CHECK
PHYSICAL/TB TEST

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

Personal

Date *

Last Name *

First Name *

Middle Name *

Street Address *

Home Phone *

City *

State *

Zip Code

Cell Phone

S.S. #

Emergency contact (person not living with you) name and #

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Online Ad

Walk-In

Agency Employee

Other

Education

College

School Name

Location

Course of Study

Graduation Year

Degree/Diploma

Trade School

School Name

Location

Course of Study

Graduation Year

Degree/Diploma

High School

School Name

Location

Course of Study

Graduation Year

Degree/Diploma

Other

School Name

Location

Course of Study

Graduation Year

Degree/Diploma

Employment

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

1. Company Name

Telephone

Address

City

State

Zip Code

Starting Pay

Dates of Employment

From

Job Title

Reason for leaving

Duties

2. Company Name

Telephone

Address

City

State

Zip Code

Starting Pay

Dates of Employment

From

Job Title

Reason for leaving

Duties

3. Company Name

Telephone

Address

City

State

Zip Code

Starting Pay

Dates of Employment

From

Job Title

Reason for leaving

Duties

Are you currently employed?

Yes

If yes, which days and times are you available?

Do you have reliable transportation?

Yes

Professional References

Persons who can furnish information about job performance

Name

Telephone

Address

Fax

Name

Telephone

Address

Fax

Name

Telephone

Address

Fax

General

Have you ever been convicted of a crime in the past 5 years?

Yes

Conviction will not necessarily disqualify an applicant from employment.

If yes, describe in full:

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

Yes

If you answered No, which job requirement can you not meet?

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed (give 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.

SIGNATURE *

DATE *