01. Application for Employment

Application for Employment
Personal Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date available:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SSN #
Please enter 9 digit Social Security number.Format: 000-00-0000.
Position Specific Information
Position applied for:
Enter position type: eg: "HHA" or select from below more options:
More options:

Other
Has your license ever been suspended or revoked?
Explain the reason:
Describe Details
Appling for:

Time Availability: (check all times you are available for work; times noted are approximate)

Rows	MON	TUE	WED	THU	FRI	SAT	SUN
8 AM TO 12 PM
12 PM TO 4 PM
4 PM TO 8 PM
8 PM TO 12 AM
12 AM TO 4 AM
4 AM TO 8 AM

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 so, when?
Describe Details
Have you ever been convicted of a felony or misdemeanor?
If yes, detail:
Describe Details
Languages Spoken:

Other
Education
High School
Address
From
To
Did you graduate?:
Degree
College
Address
From
To
Did you graduate?:
Degree
Other
Address
From
To
Did you graduate?:
Degree
Professional Reference - 1 (Can't be Family member or Friend)
Full Name
Relationship(Co-worker/Supervisor/Manager)
Company Name
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Professional Reference - 2 (Can't be Family member or Friend)
Full Name
Relationship(Co-worker/Supervisor/Manager)
Company
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous Employment
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Supervisor
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
May we contact your previous supervisor for a reference?:
Previous Employment
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Supervisor
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
May we contact your previous supervisor for a reference?:
Military Services
Branch
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rank at Discharge
Type of Discharge
If other than honorable, explain
Employment Application Disclosure and Authority to Release Information
PLEASE READ THIS STATEMENT CAREFULLY BEFORE SIGNING.
I understand that in processing my application with Galaxy Home Care, a background check will be conducted. Information may include but is not limited to: employment history, education, criminal records, national sex offender check, child abuse clearance, motor vehicle records, personal references, and any data provided on this application or during the interview process.

I authorize the appropriate individuals, companies, institutions, or agencies to release information and I release them from any liability as a result of such inquiries or disclosures.

I have read, understand, and consent to these statements by my signature. I hereby certify that all the statements and answers set forth on the application form, my resume, and interview are true and complete to the best of my knowledge. If this application leads to employment, I understand that if any statements and/or answers are found false or the information has been omitted, such false statements or omissions may cause rejection of my application or termination of my employment.
If currently employed: My current employer may be contacted?
Please list any additional addresses where you have lived, worked and attended schools during the past 7 yrs.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Address

Street Address

Street Address Line 2

CityState

Zip Code
Address

Street Address

Street Address Line 2

CityState

Zip Code
Address

Street Address

Street Address Line 2

CityState

Zip Code
Other Name(s) Used and Date(s)
DL/GC/State ID Number
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State Issued

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File Upload/Add Resume/ID's/SSN/Green Card (Front + Back)

Cancelof
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application for Employment

Personal Information

Position Specific Information

Education

Professional Reference - 1 (Can't be Family member or Friend)

Professional Reference - 2 (Can't be Family member or Friend)

Previous Employment

Previous Employment

Military Services

Employment Application Disclosure and Authority to Release Information

Please list any additional addresses where you have lived, worked and attended schools during the past 7 yrs.