Dignity Care Home Employment Application

Dignity Care Home Employment Application
Date

Month Day Year
Date
Name

First Name Last Name
License or Certification Number (if applicable):
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Are you 18 years or older?
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
Position desired:
Date you can start

Month Day Year
Date
Wage desired:
Are you employed now?
If so, may we inquire of your present employer?
Ever applied to Dignity Care Home before? When?
Who referred you to us?

Education
High School attended and location:
Number of years attended:
Did you graduate?
College, Trade, or Correspondence school attended and location:
Number of years attended:
Field of study:
Did you graduate?
Are there any other educational background, subjects of special study or special skills you'd like us to know about?

Former Employers
Most recent employer name:
Most recent employer address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start date:

Month Day Year
Date
End date (if applicable):

Month Day Year
Date
Position:
Reason for leaving (if applicable):
Second most recent employer name:
Second most recent employer address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start date:

Month Day Year
Date
End date (if applicable):

Month Day Year
Date
Position:
Reason for leaving (if applicable):
Third most recent employer name:
Third most recent employer address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start date:

Month Day Year
Date
End date (if applicable):

Month Day Year
Date
Posistion:
Reason for leaving (if applicable):
Which of these jobs did you like best?
May we inquire of your past employers?

References

Give the names of three people not related to you whom you have known for at least a year.
1. Name

First Name Last Name
Phone Number

Area Code Phone Number
Business:
Years acquainted:
2. Name

First Name Last Name
Phone Number

Area Code Phone Number
Business:
Years acquainted:
3. Name

First Name Last Name
Phone Number

Area Code Phone Number
Business:
Years acquainted:

Emergency contact and signatures
Emergency contact:

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
I certify I have not been convicted/adjudicated of an offense which prohibits employment in an adult care home pursuant to K.S.A. 39-970 or K.S.A. 65-5117 (Copy of prohibited offenses available upon request.)
Signature

Clear
Date

Month Day Year
Date
"I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the complay's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other that it's president, and then only when in wrong and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing."
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Dignity Care Home Employment Application

Education

Former Employers

References

Emergency contact and signatures