NCI & AHI Employment Application

NCI & AHI Employment Application
Personal Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Do you have a valid California Driver's License?

Yes No
Have You had it for more than 2 years?

Yes No
Employment Desired
Position Desired
Desired Salary
How did you hear about this position?
Date available to start

Month Day Year
Date
Desired hours: (full time or part time)
Days Available
Hours available
Education
School or Institution
Location: City & State
Degree
List any seminars, classes, or other education which may help you qualify for this position.
Employment History

List below all present and past employers over the past ten years, starting with your most recent employer. Account for all periods of unemployment.
Employer
Current employer?

Yes No
May we contact?

Yes No
Employer's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer's Phone Number
Please enter a valid phone number.
Supervisor's Name
Supervisor's Email
example@example.com
Your Job Title
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Essential Job Duties
Reason(s) for leaving: (or wanting to leave if currently employed)
Employer
Current Employer?

Yes No
May we contact?

Yes No
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer's Phone Number
Supervisor's Name
Supervisor's E mail address
example@example.com
Your job title
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Essential Job Duties
Reason(s) for leaving: (or wanting to leave if currently employed)
Employer
Current Employer?

Yes No
May we contact?

Yes No
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer's Phone Number
Supervisor's Name
Supervisor's E mail address
example@example.com
Your job title
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Essential Job Duties
Reason(s) for leaving: (or wanting to leave if currently employed)
Additional Information
Do you speak any languages other than English?
Speak

Fluent Good Fair
Read

Fluent Good Fair
Write

Fluent Good Fair
Have you ever worked for this company before?

Yes No
When?
Do you have any friends or relatives employed by this company?

Yes No
Please provide their names and relationship to you:
Personal or Professional References

List below three persons not related to you who have knowledge of your work performance within the last 5 years
Name
This reference is:

Professional Personal
Occupation
Company name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone
E mail
example@example.com
Relationship & years acquainted
Name

First Name Last Name
This reference is:

Personal Professional
Occupation
Company name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone
E mail
example@example.com
Relationship & years acquainted
Name

First Name Last Name
This reference is:

Personal Professional
Occupation
Company name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone
E mail
example@example.com
Relationship & years acquainted
Please read each statement closely and initial each acknowledging your understanding
Investigation Authorization: I authorize an investigation into all statements and references contained in this application. Said investigation may include interviews with past employers, workers, and friends. Said investigation may include credit, driving, criminal background, drug screenings, references, and other background checks. As a condition of applying for this job, I authorize reasonable post-offer investigations into my credit, driving, and criminal background. I authorize the references and contacts listed to provide the agency with any and all relevant information, personal or otherwise, and to the fullest extent allowed by law, I release all parties from all liability for any damages that may result from furnishing the same to the agency.
Initials:
Company Obligation: I understand and agree that the Company's acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as a result of accepting this completed application.
Initials:
Fingerprints: All employees are required to submit their fingerprints by 'Live Scan' for clearance through the Department of Justice and/or FBI. Failure of fingerprints to clear or failure to list any crime may be grounds for termination. The employer covers the cost.
Initials:
Driver's License, DMV History & Vehicle Insurance Both agencies require driving for agency business; therefore, all applicants must have a valid CA Driver's License (2 years minimum) clean Driving Record, and provide proof of valid auto insurance. Applicants must be considered an acceptable driver by the agency's insurance carrier. If an applicant is uninsurable by the agency's carrier, the applicant cannot be employed by the agency.
Initials:
First Aid/CPR All Direct Service Staff are required to successfully complete, a First Aid/CPR training course arranged and provided by the employer. Staff who fail to meet this requirement may not work again until they have successfully completed the training. The employer covers the cost.
Initials:
Proof of Right to Work: At the time of hire you will be required to present proof of your right to remain and work in the U.S.A.
Initials:
Arbitration: You understand that, if offered employment, you will be required to sign an agreement requiring you to arbitrate almost all claims you might have against the agency in the future. You hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application in accordance with the terms of that Agreement.
Initials:
I CERTIFY UNDER PENALTY OF PERJURY PURSUANT TO THE LAWS OF THIS STATE THAT MY ANSWERS ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I AM AWARE THAT FAILURE TO COMPLETE THIS APPLICATION, INTENTIONAL OMISSIONS, OR MISSTATEMENTS MAY RESULT IN REFUSAL OF EMPLOYMENT OR DISCHARGE. I UNDERSTAND IF HIRED, MY EMPLOYMENT WILL BE “AT-WILL,” FOR NO DEFINITE OR SPECIFIC PERIOD OF TIME AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, FOR ANY REASON, OR FOR NO REASON AT ALL, WITH OR WITHOUT PRIOR NOTICE AT THE OPTION OF THE AGENCY OR ME. I ALSO UNDERSTAND THAT OFFERS OF EMPLOYMENT MAY BE CONTINGENT ON A SATISFACTORY BACKGROUND CHECK, INCLUDING A REVIEW OF MY CRIMINAL HISTORY. I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.
Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

NCI & AHI Employment Application

Personal Information

Employment Desired

Education

Employment History

Additional Information

Personal or Professional References

Please read each statement closely and initial each acknowledging your understanding