Official Application of Jenesis Healthcare Group

(This type of application should be completed by all who seek any position that will involve the supervision and/or custody of children or youth. You should tailor the application to the specific circumstances in your congregation. However, the employment application should include sections for personal identification, job qualifications, experience and background for the past 5-10 years, references, a criminal history, and a waiver/consent to a periodic criminal records check or fingerprinting
Jenesis Healthcare Group
APPLICANT INFORMATION
EMPLOYMENT APPLICATION
Todays Date

MonthDayYear
Date
How Did You Hear About Us?
(First)
(Middle)
Name (Last)
Address

Address

Street Address Line 2

CityState

ZIP Code
Telephone
Alternate Telephone
Best Contact Time
E Mail Address
example@example.com
Driver's License No./Issuing State
Social Security Number
Date of Birth

MonthDayYear
Date
Position Apply For
DayNightEveningWeekend
When Are You Available to Begin Work?
Will You Work Overtime?
YesNo
In Case of Emergency Notify
Telephone
Name of Nearest Relative
Telephone
EDUCATION
DEGREE/DIPLOMA
BUSINESS/TECHNICAL
Professional Organizations
Date Completed

MonthDayYear
Date
Date Completed

MonthDayYear
Date
EMPLOYERS
(List all jobs and contracts held by you during the past five continuous years)
CURRENT EMPLOYER
Company Name
Telephone
Address

AddressCity

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held From and To
Starting Salary
Ending Salary
Reason for Leaving
Company Name
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
City
Position Held
Company Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Leaving
Supervisor
PREVIOUS EMPLOYER
Company Name
Address
Position Held
Supervisor
PREVIOUS EMPLOYER
Company Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
MILITARY STATUS
Have You Served in the U.S. Armed Services?
Special Training/Experience Received in the U.S. Armed Services
CRIMINAL HISTORY
Have you ever been convicted of a criminal offense?
Yes or No
Do you currently have any criminal actions pending in which you are the Defendant? (Not Applicable to California Applicants)
Yes or No
Are you currently on probation or parole?
Yes or No
If you answered "Yes" to any of the above questions, please explain the nature of the offense and provide the date of the offense and the county and state in which it occurred.
APPLICANT STATEMENT
(Read and Sign Below) I certify that this employment application was completed by me and that all of the information on this application is true and correct to the best of my knowledge.

Iunderstand that any falsification, misrepresentation, or omission of facts called for herein will result in my

disqualification from further consideration or dismissal from employment if I am hired. I have reviewed the Authorization for Criminal Records Verification and Fingerprint Information and acknowledge that I understand the terms set forth therein. I understand that this employment application is not valid without my signature.
Print Full Name
Signature

Clear
Date

MonthDayYear
Date
CHURCH MUTUAL INSURANCE COMPANY AND HERMES SARGENT BATES WISH TO POINT OUT THAT NO WARRANTY ATTACHES TO THESE DOCUMENTS, AND IN FACT, THESE DOCUMENTS MAY NOT BE APPROPRIATE FOR THE SPECIFIC NEEDS OF A PARTICULAR ENTITY. THESE DOCUMENTS ARE NOT A SUBSTITUTE FOR GOOD PRACTICE, PROPER SUPERVISION, AND DILIGENT OVERSIGHT AND

CONTROL. THERE is NO GUARANTEE THAT THESE DOCUMENTS WILL PROTECT ANY FACILITY THAT CHOOSES TO USE THEM. BEFORE

USING THESE DOCUMENTS OR ANY SIMILAR DOCUMENTS, YOU SHOULD CONSULT WITH YOUR OWN ATTORNEY TO MAKE CERTAIN THAT THE DOCUMENT YOU EVENTUALLY USE IS CORRECT AND CURRENT UNDER THE LAW OF YOUR PARTICULAR JURISDICTION AND THAT THE DOCUMENT MEETS YOUR NEEDS FOR YOUR PARTICULAR SITUATION.
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Jenesis Healthcare Group

APPLICANT INFORMATION

EMPLOYMENT APPLICATION

EDUCATION

DEGREE/DIPLOMA

BUSINESS/TECHNICAL

EMPLOYERS

CURRENT EMPLOYER

PREVIOUS EMPLOYER

PREVIOUS EMPLOYER

MILITARY STATUS

CRIMINAL HISTORY

APPLICANT STATEMENT