APPLICATION FOR EMPLOYMENT OR CONTRACT

RESTORE HOME HEALTH AGENCY
APPLICATION for EMPLOYMENT or
CONTRACT

Form 400B
o 2011 All Rights Reserved. Coleman Consulting Group. Inc.

Photocopy this document only for internal Agency use
PERSONAL
Last Name*
First*
Initial*
Social Security #*
Other Name(s) Used
Home Telephone # ()
Format: (000) 000-0000.
Address*
Cell or Message #*
Position Applied For*
Referred By
Salary Desired*
YesNo
If yes, list date(s)

MonthDayYear
Date
If yes,list job titles & locations
YesNo
If yes, list date(s)

MonthDayYear
Date
If yes, list dates job titles & locations
YesNo
If yes, list date(s)

MonthDayYear
Date
If yes, list job titles & locations
YesNo
If under 18, do you have a work permit?
EDUCATION
Please check Highest Grade Completed:
9101112
1234
Graduate Studies
High School*
High School*
Major Studies
Degree, Diploma, License or Certificate
College/University
Address
Major Studies
Degree, Diploma, License or Certificate
Vocational, Business, Other
Address
Major Studies
Degree, Diploma, License or Certificate
List Any Professional Designations
In what language(s) other than English are you fluent? Write Speak Read Language:
Language
Speak SpeakReadWrite
Language
SpeakReadWrite
Language
SpeakReadWrite
For Clerical Applicants Only
NoYes
If yes, WPM
Computer Skills (Hardware/Software)
o 2011 All Rights Reserved. Coleman Consulting Group. Inc.

Photocopy this document only for internal Agency use
EMPLOYMENT HISTORY
List prior five (5) years of employment history, starting with the most recent position. All information must be completed. You may attach a resume, but not in place of completing the required information. Pierce-Foley, LLC (DBA- Always Best Care Home Health) will contact at least two previous employers to verify the position held, dates of employment and eligibility for rehire. Ask for an additional Employment History Sheet, if needed.
Employed From*
Employer Name*
Supervisor Name
Starting Salary
Employed Until*
Employer Address*
Supervisor Phone #*
Format: (000) 000-0000.
Ending Salary
Job Title
Reason for Leaving
Duties and Responsiblities
Employed From
Employer Name
Supervisor Name
Starting Salary
Employed Until
Employer Address
Supervisor Phone #
Format: (000) 000-0000.
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
Employed from
Employer Name
Supervisor Name
Starting Salary
Employed Until
Employer Address
Format: (000) 000-0000.
Supervisor Phone #
Format: (000) 000-0000.
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
Employed from
Employer Name
Supervisor Name
Starting Salary
Employed Until
Employer Address
Supervisor Phone
Format: (000) 000-0000.
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
o 2011 All Rights Reserved. Coleman Consulting Group. Inc.

Photocopy this document only for internal Agency use
GENERAL
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
3PM-11PM7AM-3PM11PM-7AM
YESNO
CERTIFICATION & AUTHORIZATION
The above information is true and correct. I understand that, in the event of my employment or contract by the Company, I shall be subject to dismissal if any of the information I have given in this application is false or misleading. or if I have failed to give any information herein requested. regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information

I understand that nothing in this application, the granting of an interview or my subsequent employment or contract with the Company. is intended to create an employment contract between myself and the Company. On the contrary I understand and agree that, if hired or contracted. my association will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing.

I hereby acknowledge that I have read and agree to the above statements.
Signature*

Clear
Date*

MonthDayYear
Date
o2011 All Rights Reserved. Coleman Consulting Group. Inc.

Photocopy this document only for internal Agency use
Should be Empty:

RESTORE HOME HEALTH AGENCY

APPLICATION for EMPLOYMENT or

CONTRACT

PERSONAL

EDUCATION

EMPLOYMENT HISTORY

GENERAL

CERTIFICATION & AUTHORIZATION