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Position Applying For*
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References

Please List 3 References:
Reference 1
Name:   First Name*   Last Name*
Position:   Type a label*
Address:   Street Address*      City*   State*   Zip*
Phone:   Area Code*   Phone Number*
Reference 2
Name:   First Name*   Last Name*
Position:   Type a label*
Address:   Street Address*      City*   State*   Zip*
Phone:   Area Code*   Phone Number*
Reference 3
Name:   First Name   Last Name
Position:   Type a label
Address:   Street Address      City   State   Zip
Phone:   Area Code   Phone Number
Education History
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Trade School:   Type a label*   Yrs:   Type a label*
College:   Type a label*   Yrs:   Type a label*
Work History

Please List 3 References:
Reference 1
Company Name:   First Name*
Position:   Type a label*
Address:   Street Address*      City*   State*   Zip*
Phone:   Area Code*   Phone Number*
Start Date:   Date   End Date:   Date
Reference 2
Company Name:   First Name   Last Name
Position:   Type a label
Address:   Street Address      City   State   Zip
Phone:   Area Code   Phone Number
Start Date:   Date   End Date:   Date
Reference 3
Company Name:   First Name   Last Name
Position:   Type a label
Address:   Street Address      City   State   Zip
Phone:   Area Code   Phone Number
Start Date:   Date   End Date:   Date
APPLICATION FORM WAIVER

In exchange for the consideration of my job application by 1630 Serene Care Solutions, (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of 1630 Serene Care Solutions, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and 1630 Serene Care Solutions may end the employment relationship at any time, without specified notice or reason.I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.I further understand that my employment with the Company shall be probationary for a period of sixty (60)days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
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APPLICATION FORM WAIVER