Sponsor Application

Sponsored Residential Application

Impact Infusions LLC
Name

First NameLast Name
Todays Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date Available

MonthDayYear
Date
SSN#
Drivers License #
State
Exp Date

Have you had any accidents in the past three years? If yes how many?
Have you had any moving violations in the past three years? If yes how many?
Position Applied for:
Are you a citizen of the United States? If no, are you authorized to work in the U.S.?
Can you travel if job requires?
Have you ever worked for this company or applied with us before? If yes, when?
Are you currently employed? If yes, may we contact your employer?
Are you able to perform essential functions of the position without Accommodations? (Lifting, bending, walking, etc)
Have you ever been convicted of a felony? If yes, please explain
Have you ever provided sponsored services in your home? If yes, which agency?
Dates Of Service

MonthDayYear
Date
Are you currently a sponsor with another agency? If yes, which agency?
Contrate End Date

MonthDayYear
Date
Are you currently under contract with another sponsor agency? If yes, which agency?
Contrate End Date

MonthDayYear
Date
Please list other special skills you would like considered for the position for which you are applying:

Education
References

Previous Employment
Military Service

AT-WILL EMPLOYMENT
It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization.

CERTIFICATION OF TRUTH AND ACCURACY
I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.

NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION
I understand that I may be subject to a background check, and hereby authorize Impact Infusions, LLC to investigate my background to determine any and all information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information.
Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, and criminal records through an investigative bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required.
I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired.

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature

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Date
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Sponsored Residential Application