PERSONAL DATA
First Name
*
Middle Name
Last Name
*
Maiden Name
Phone:
*
Please enter a valid phone number.
Email:
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you find out about this job?
*
Do you have access for an appropriate in home office setting, with internet access, fax, Microsoft Word and a cell phone?
*
Yes
No
Minimum Salary Expected
*
Are you at least 18 years old?
*
Yes
No
Driver’s License Number
*
State Issued
*
Expiration Date
*
-
Month
-
Day
Year
Date
Are you legally eligible for employment in the U.S.? Proof of U.S. citizenship or immigration status will be required if hired.
*
Yes
No
Have you been convicted of a crime?
*
Yes
No
State the nature of the offense and disposition of the case. Include dates and places. (NOTE: The existence of a criminal record does not constitute an automatic bar to employment.)
EMPLOYMENT DATA
Status
*
Full Time
Contract
Which position are you applying for?
*
Are you willing to be on the road driving for up to 75% of the time?
*
Are you comfortable going into client's homes?
*
Are you currently employed?
*
Yes
No
If hired, when would you be able to start?
*
Have you ever worked for OCS?
*
Yes
No
What name did you use when you were last employed with OCS?
List any friends or relatives employed by this company
Are you on layoff and subject to recall?
*
Yes
No
Have you ever been discharged or asked to resign from any position?
*
Yes
No
Please explain the reason for discharge or resignation
Are you able to perform all the tasks for the job you are applying for?
*
Yes
No
Please explain why you can not perform the tasks for the job you are applying for
EDUCATION HISTORY
College #1
Name
*
Address
*
Highest Degree Obtained
*
Please Select
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
None
Major
*
Minor
*
Did you graduate?
*
Yes
No
Graduation Date
*
-
Month
-
Day
Year
Date
What Was your Last Name at Graduation?
*
College #2
Name
Address
Highest Degree Obtained
Please Select
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
None
Major
Minor
Did you graduate?
Yes
No
Graduation Date
-
Month
-
Day
Year
Date
What Was your Last Name at Graduation?
College #3
Name
Address
Highest Degree Obtained
Please Select
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
None
Major
Minor
Did you graduate?
Yes
No
Graduation Date
-
Month
-
Day
Year
Date
What Was your Last Name at Graduation?
Professional Licenses #1
Name
State Issued
License Number
Expiration Date
-
Month
-
Day
Year
Date
Professional Licenses #2
Name
State Issued
License Number
Expiration Date
-
Month
-
Day
Year
Date
Professional Licenses #3
Name
State Issued
License Number
Expiration Date
-
Month
-
Day
Year
Date
List any other certifications or their specialties
MILITARY HISTORY
Are you a veteran?
*
Yes
No
Date Served From:
Date Served To:
List any special skills or training:
EMPLOYMENT HISTORY
EMPLOYER #1
Company Name
Phone Number
Address
City, State, Zip
Date Employed From
Date Employed To
Beginning Salary
Ending Salary
Job Title
Supervisor`s Name & Title
May we contact this person?
Yes
No
Why not?
Describe Duties
Specific Reason for Leaving
EMPLOYER #2
Company Name
Phone Number
Address
City, State, Zip
Date Employed From
Date Employed To
Beginning Salary
Ending Salary
Job Title
Supervisor`s Name & Title
May we contact this person?
Yes
No
Why not?
Describe Duties
Specific Reason for Leaving
EMPLOYER #3
Company Name
Phone Number
Address
City, State, Zip
Date Employed From
Date Employed To
Beginning Salary
Ending Salary
Job Title
Supervisor`s Name & Title
May we contact this person?
Yes
No
Why not?
Describe Duties
Specific Reason for Leaving
EMPLOYER #4
Company Name
Phone Number
Address
City, State, Zip
Date Employed From
Date Employed To
Beginning Salary
Ending Salary
Job Title
Supervisor`s Name & Title
May we contact this person?
Yes
No
Why not?
Describe Duties
Specific Reason for Leaving
Please read the following carefully, then check accept and date the application.
I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company. Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third-party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations. I hereby agree to submit to any drug test required, whether prior to my employment or if employed by this company at any time thereafter. If requested, I will take a post job offer physical examination and my employment, in the event I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job-related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider and a company-designated physician. I further understand this is an application for employment and no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and the company may change wages, benefits, and conditions at any time. My employment is at will. No individual with the company is authorized to change the employment-at-will status except an officer of the company, who may do so only in writing. I have read and agree to the above.
If you agree to the above statement please check the box below
*
I agree that all information above and have checked and acknowledge the information that have been input into this form is accurate.
Submit
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