Rewind Inc. Application for Employment

Application for Employment

Rewind Inc.
Personal information
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security Number
Date of Birth *

Month Day Year
Date
Qualifications for Employment
Are you 18 years or older?
Have you been free of Substance use and alcohol use Disorders for at least two years preceding the date of this application to qualify for hire by Rewind Inc.?
Employment Desired
Position applying for: Date available: Date
Physical Record
Do you have any physical limitations that preclude you from performing any work for which you are being considered?
Explain:
Employment Record

List all employers for the past five (5) years
If applying for a position which provides psychological services, an inquiry will be made to those employers regarding substantiated sexual contact with a client.

Employer:
Address:   Street Address      City   State   Zip
Dates Employed:  from Date    to    Date
Position Held:

Employer:
Address:   Street Address      City   State   Zip
Dates Employed:  from Date    to    Date
Position Held:

Employer:
Address:   Street Address      City   State   Zip
Dates Employed: from   Date    to   Date
Position Held:

Employer:
Address:   Street Address      City   State   Zip
Dates Employed: from   Date    to   Date
Position Held:
Education Record
School:      Address/State:         City   State
Date: from   Date    to   Date
Degree:    Subjects Studied:

School:       Address/State:         City   State
Date: from   Date   to   Date
Degree:      Subjects Studied:

School:      Address/State:         City   State
Date: from   Date    to   Date
Degree:       Subjects Studied:
References:

List three names of persons not related to you
Reference #1
Name: First Name   Last Name   Occupation:
Address:   Street Address   Address Line 2   City   State   Zip Years Acquainted:

Reference #2
Name:   First Name   Last Name   Occupation:
Address:   Street Address   Address Line 2   City   State   Zip   Years Acquainted:

Reference #3
Name:   First Name   Last Name   Occupation:
Address:   Street Address   Address Line 2   City   State   Zip   Years Acquainted:
Staff Qualifications specific to Job Description:
Attach personal resume, if applicable

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Cancel of
In Case of Emergency Notify

Name: First Name Last Name Relation:
Address: Street Address Address Line 2 City State Zip Phone: Area Code Phone Number
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 investigation of all statements contained herein. I give the references listed above permission to give you any and all information concerning my previous employment, any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

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

Clear
Month Day Year
Date
Should be Empty:

Application for Employment

Personal information

Qualifications for Employment

Employment Desired

Physical Record

Employment Record

Education Record

References: