APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
POSITION APPLIED FOR
Date

MonthDayYear
Date
Last
First
Middle
Street
Apt
City
State
Zip Code
Phone Number
Cell Number
EMAIL ADDRESS
Type of Employment Desired

Full TimePart TimePer Diem
NURSING/CNA LICENSE NO. If Applicable
STATE
Date Available for Work

MonthDayYear
Date
Are there any hours, shifts or days you cannot or will not work?

YesNo
If YES, when
Were you known to any employer, school, or reference by another name?

YesNo
IF YES, Please indicate name
If you are under the age of 18, can you furnish a work permit?

YESNo
Have you ever been employed here before?

YesNo
Are you legally eligible for employment in this country?

YesNo
Proof of U.S. Citizenship or immigration status will be required upon employment

Skills & Qualifications Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our company.
Educational Background

	Name & Location	Years Completed	Graduate? What was Major/Degree?	Course of Study
High School
College
Other

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our company.
Employment History

Please list your last (4) employers, assignments, or volunteer activities, starting with the most recent, including military experience
Employer 1
Employer
Phone Number
Please enter a valid phone number.
From
To
Job Title
Address
Immediate Supervisor & Title
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Employer 2
Employer
From
To
Phone Number
Please enter a valid phone number.
Job Title
Address
Immediate Supervisor & Title
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Employee 3
Employer
From
To
Phone Number
Please enter a valid phone number.
Job Title
Address
Immediate Supervisor & Title
Summarize the nature of work performed and job responsibilities
Reason for Leaving
Employee 4
Employer
From
To
Phone Number
Please enter a valid phone number.
Job Title
Address
Immediate Supervisor & Title
Summarize the nature of work performed and job responsibilities
Reason for Leaving

References

I hereby certify that I have read and fully completed this application and that the facts set forth in this employment application (and accompanying resume. if any) are true and correct to the best of my knowledge. and I agree and understand that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. Furthermore, I understand that just as am free to resign at any time. the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make assurances to the contrary. Igive the employer the right to investigate all references and to secure additional information about me if job related I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.
Signature

Clear
Date

MonthDayYear
Date
Itis unlawful in the Commonwealth of Massachasetts to require or administer a lie detector test as a condition of employment or continued employment An employer who violates this law shall be subject to criminal penalties and civil liability.
Should be Empty:

Educational Background