Application- Connection Point Services,LLC

Application Form
Please complete all sections on this form
Name*

First NameLast Name
Previous Names (supply documentary evidence)
Title
Date of Birth*

MonthDayYear
Date
Current Address*

Street Address

Street Address Line 2

CityPostal Code

County
Email Address*
example@example.com
Phone Number*
Data Protection Statement The personal information (data) collected on this form, are used only for the purpose of this employment. Equality of Opportunity Statement The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.
Position Applied For*

Approx number of hours wanted*
Select working Time*

FullPart Time
Preferred Shift*

DaysEveningsWeekendsAfternoonsMornings
Do you have reliable transportation?*

YesNo

Education
Add Educational Qualifications*
What Nursing or relevant designations, licenses, certificates, or registrations if any, do you possess? *
Please upload copies of your certificates

Cancelof

Employment History
Details of past employment starting with the most recent
Please give details of relevant experience. This may be taken from the work situation, voluntary work, charity or your own home.
Experience

Capacity to work in the US
Are you legally eligible for employment in this country?*

YesNo
If you are successful in the application, would you require PCA/CNA training prior to taking up employment?*

YesNo
References
You must provide references from your most recent employer. If you have no work history, please list a teacher or professional reference. Please provide an additional character reference. All are subjected to being contacted, therefore please inform the references of the fact that you have used their name. If you are unable to provide the required references, please discuss the matter with us.
Add your references (starting with the current or most recent one)*
Character reference*
Have you been convicted of a crime in the last seven (7) years?*

YesNo
If so, please list details below:
CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT.
SIGNATURE and DECLARATION IMPORTANT BEFORE SIGNING
I certify that all the information I have provided is true, complete, and correct.
The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
I authorize the employer to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal.
I understand that if I am hired, I will be required to provide criminal background check, proof of identity and legal authority to work in Virginia, proof of certifications or educational qualifications, and a driver abstract (if applicable). Additionally, I
give Connection Point Services, LLC permission to take $20.00 dollars out of my first paycheck for my criminal background check.
Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior
notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.
Should be Empty:

Application Form

Education

Employment History

Capacity to work in the US

References