Employment Application Form

Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

Area CodePhone Number

E-mail Address:*

Date Available

Date

Desired Salary

Social Security No.*

Highest Form of Education*

High School Name*

*Please note that you will need to provide a copy of your Diploma or GED Transcripts upon hire

University, College, Trade School Name or Military Experience *if applicable

Are you CPR Certified *

*Not required for hire

Have you had a background check within a year?*

*Not required for hire

Are you a citizen of the United States?*

If NO, are you authorized to work in the U.S.?*

Have you ever worked for this company?*

If YES, when?

Have you ever been convicted of a felony?*

If YES, explain:

Upload Resume:

Upload a File

Previous Employment

Company *

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Supervisor Name*

Job Title*

Describe Responsibilities:*

Start Date

Date

End Date

Date

Reason for Leaving

References

Please list two (2) references that are familiar with your work life.

Reference 1

Name:*

First NameLast Name

Relationship

Phone Number*

Area CodePhone Number

Years Known:*

Reference 2

Name:*

First NameLast Name

Relationship

Phone Number*

Area CodePhone Number

Years Known:*

Do you have a valid Driver's License?*

Can you provide proof of insurance?*

Have you had your license suspended or revoked in the last 3 years*

Please Select the days and times of the week you are available to work *

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY	SATURDAY	SUNDAY
1:00am
2:00am
3:00am
4:00am
5:00am
6:00am
7:00am
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
6:00pm
7:00pm
8:00pm
9:00pm
10:00pm
11:00pm
12:00am

Do you have any allergies that would affect your work at RHHH?*

If yes, please list here

Do you have a problem working with a client who smokes*

How many hours a week are you willing to work?*

If Hired:

I agree to notify R House within 14 days of being convicted or pleading guilty to a disqualifying offense. I agree to notify R house within 14 days of any traffic violations convictions resulting in 6 or more points on my license or any offense resulting in suspension or revocation of my driver's license.

I certify that my answers are true and complete to the best of my knowledge. I undertand that the information provided in this application will be used to obtain a backround and reference check.

If this application lead to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature*