Employment Application Form

Employment Application

Their Strength Companionships for Mental Health LLC
By completing this application, you understand and accept that you are applying for a position as an "At Will" employee. "At Will" employment means that either you or the Company can terminate your employment with or without cause and with or without notice.
Name:*

First NameMiddle InitialLast NameSuffix
Other Names by which you have been known (if any)

First NameMiddle InitialLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Home Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
E-mail Address:*
Emergency Contact*

NamePhoneE-Mail

Employment History

Start with your current or most recent employer and work backwards regarding all former employers.
Current or Most Recent Employer:*
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week Reason for Leaving
May we Contact this Employer?*
Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week Reason for Leaving
May we Contact this Employer?
Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week Reason for Leaving
May we Contact this Employer?
References

Please list two references that are familiar with your work life.
Reference 1
Name:

First NameLast Name
Phone Number

Area CodePhone Number
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Click to edit
Reference 2
Name:

First NameLast Name
Phone Number

Area CodePhone Number
Years Known:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

1. Can you provide proof of eligibility to become employed in the United States?*
If no on #1, are you able to provide such proof which will be required upon employment if you are offered a position?
2. If you are under the age of 18, can you provide required proof of your eligibility to work?*
3. Are you currently on layoff status and subject to recall?*
4. Do you have adequate transportation to meet travel requirements of the job?*
5. Do you have a current valid drivers license?*
If yes, please state the following:
Issuing StateExpiration Date
6. Are you able and willing to travel for this job if travel is necessary?*
7. Are you aware of any reason that may restrict your ability to perform the essential functions of the job for which you are making application?*
If yes, please explain and describe what accommodations might be necessary:
8. Have you ever been terminated or forced to resign from your employment with any employer?*
If yes, please explain:
9. Have you ever been convicted of a crime including any driving and/or alcohol-related offenses?*
If yes, please explain:

Employment Application