Employment Application

Full Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

Driver's License Number*

12 345 678

Position Applying For*

Part Time or Full Time?*

How did you learn about this position?

Do you have any relatives or friends that work here*

YesNo

If so, list them here

Are you at least 18 years old?*

YesNo

Are you able to submit proof that you are legally eligible for employment in the United States*

YesNo

Are you able to perform the essential functions of this position with or without reasonable accommodations?*

YesNo

List any skills or abilities that may be useful for the job you are seeking. Enter the number of years of experience and circle the number which corresponds to your ability for each particular skill. (1 represents poor ability, 5 represents exceptional ability)

Are you willing to work any shift, including nights and weekends?*

YesNo

If you can work any time, write NO RESTRICTIONS. If you cannot work on a given day, write NO AVAILABILITY. All Week shifts are 8 hour shifts. The shifts are: 8am-4pm, 4pm-12am, 12am-8am. All Weekend shifts are 12 hour shifts. The shifts are: 8am-8pm, 8pm-8am. Please include A.M. and P.M.*

	No Restrictions	8AM-4PM	4PM-12AM	12AM-8AM	No Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are you able to work overtime?*

YesNo

If offered, when are you able to begin work?*

Name of High School or place where HS Diploma or GED received*

College / University(s) Name and Address?

Did you receive a degree?

YesNo

Please indicate any current professional licenses or certifications that you hold?

List any relevant skills

License or certificate number?

List any relevant skills

Military Service?

YesNo

Relevant Skills

List any relevant skills

Qualifications

List any relevant certifications or qualifications

Current Employer*

Name of Current Employer or NONE if not Employed

Position*

Reason for Leaving?*

Start Date*

Date

May We Contact?

YesNo

Previous Employer*

Name of Previous Employer

Position*

Reason for Leaving?*

Start Date*

Date

End Date*

Date

Previous Employer*

Name of Previous Employer

Position*

Reason for Leaving?*

Start Date*

Date

End Date*

Date

Previous Employer

Name of Previous Employer

Position

Reason for Leaving?

Start Date

Date

End Date

Date

Reference 1*

Name of Reference

Relationship*

Phone*

Address

Reference 2*

Name of Reference

Relationship*

Phone*

Address

We are committed to providing quality and ethical care to our patients, residents, and consumers. We are also committed to providing a safe environment for our patients, residents, consumers, and employees. Therefor; it is also the policy of our company to conduct a pre-employment drug screen. Once a conditional offer of employment has been made, we will run a background check on all employees. If your position requires that you drive a vehicle, we will also obtain a DMV clearance. Failing the background check shall be just cause to terminate your employment. If you fail the DMV clearance, and your position requires you to drive a vehicle, you may be terminated or experience a change in employment status.

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I certify that the information provided on this application is truthful and accurate. I understand that omitting information, or providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Lead the Way, LLC to contact former employers, educational organizations, and non-relative references regarding my employment, character, and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades.

I authorize those persons designated as references to fully and freely communicate information regarding my character, previous employment, and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Director, the employment relationship will be "At-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice.

Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Lead the Way, LLC Home, except in a specific written contract of employment signed on behalf of the organization by its Executive Director, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Signature - To acknowledge you have read the information above.*

First and last name

Signature Date*

MM-DD-YYYY

Employment Application Form:

Personal Information:

Employment Desired:

Eligibility & Availability:

Education & Training:

Skills/Qualifications:

Current Employment:

Previous Employment:

References:

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