Application for Employment or Lease

Elements Holistic Wellness
Application for Employment or Room Lease

Please fill out as completely and honestly as possible.
PERSONAL INFO
I am applying for:
If you selected support staff, please specify:
Full Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail
Preferred Way to Contact
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
More Information about Availability: Is there anything else we should know about your available schedule?
Are you currently on any insurance panels? What are your customary rates?
Are you currently a citizen of the United States?
If no, are you authorized to work in the United States?
Have you ever been convicted of a felony?
If yes, explain
Date Available

MonthDayYear
If selected for employment, would you be willing to submit to a pre-employment drug screening?
If selected for employment, would you be willing to submit to a pre-employment backgound check?
EDUCATION
High School
High School Address (City, State)
Did you graduate?
Graduation Date
College 1
College Address (City, State)
Did you graduate?
Graduation Date
Degree
College 2
College Address (City, State)
Did you graduate?
Graduation Date
Degree
Other
Address (City, State)
Did you graduate?
Graduation Date
Degree
Other Education Information
PROFESSIONAL REFERENCES: Please provide information for three references.
Full Name

First NameLast Name
Relationship
Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Relationship
Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Relationship
Company
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
MILITARY SERVICE
Not Applicable
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, please explain:
PREVIOUS EMPLOYMENT: Start from most recent.
Company (Most Recent)
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Supervisor
Job Title
Salary
Responsibilities
From
To
Reason for leaving
May we contact your previous supervisor for a reference?
Company 2
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Supervisor
Job Title
Salary
Responsibilities
From
To
Reason for leaving
May we contact your previous supervisor for a reference?
Company 3
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Supervisor
Job Title
Salary
Responsibilities
From
To
Reason for leaving
May we contact your previous supervisor for a reference?
Additional Previous Employment

0/1500
About You
Tell us a little about yourself. Who are you? What are your current plans for this year? What do you like to do for fun?
Downloads
Resume

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Cover Letter

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Acknowledgement and Authorization
Acknowledgement and Authorization: Please check all 3 to be considered for employment.
Electronic Signature: Please write out full name and today's date.
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Elements Holistic Wellness

Application for Employment or Room Lease

PERSONAL INFO

EDUCATION

PROFESSIONAL REFERENCES: Please provide information for three references.

MILITARY SERVICE

PREVIOUS EMPLOYMENT: Start from most recent.

About You

Downloads

Acknowledgement and Authorization