Application for Employment

Application for Employment

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
Personal Information
Name:*

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Social Security Number (no dashes)*
Driver's License / ID*
State*
Date of Birth*

MonthDayYear
Date
E-mail Address:*
example@example.com
Have you ever applied for employment with this Agency?

YesNo
Have you ever applied for employment with this Agency?

YESNO
How many hours are you available for work? blank
Are you legally eligible for employment in the United States?

YESNO
How did you learn of our organization?

Newspaper AdAgency EmployeeOther
Are you willing to work:*

EveningsWeekends
Position applying for:

Type a question

	School Name / Location	Major	Years of Study/Degree
College / Graduate
Vo-Tech / Trade
High School
Others

Employment

Please upload your most recent resume below. Documents should list the last five years employment history, starting with the most recent employer. Documents should also include starting and ending pay, job title and work completed and a reason for leaving if applicable.
Upload Resume:

Cancelof
Was your last name different from your present name during the above listed jobs?

YESNO
If yes, what was your name?blanks
Are you currently employed?

YESNO
Do you have reliable transportation / the ability to reach multiple clients?

YESNO
TWO (2) Professional / Personal Reference Check
Reference Name 1:*

First NameLast Name
Reference Phone 1:*
Please enter a valid phone number.
Reference City & State 1*
If Professional Reference: Position Held 1
Reference Name 2:*

First NameLast Name
Reference Phone 2:*
Please enter a valid phone number.
Reference City & State 2*
If Professional Reference: Position Held 2
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

YESNO
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:
Are you capable of performing the job set forth in the job description?

YESNO
If you answered No, which job requirement can you not meet?
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.
I, blanks authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.
Signature*

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Date of Signature*

MonthDayYear
Date
Should be Empty:

Application for Employment

Personal Information

Employment

TWO (2) Professional / Personal Reference Check

GENERAL