Pure Hearts Employment Application

APPLICATION FOR EMPLOYMENT

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
PERSONAL INFORMATION
Name*

First NameLast Name
Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number*
Please enter a valid phone number.
Social Security Number*
Driver’s License / ID*
State*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Have you ever applied for employment with this Agency? YES   NO*

How many hours a week are you available for work?     *

Are you legally eligible for employment in the United States? YES   NO*

How did you learn of our organization?
Google   Newspaper Ad   Employee   Other

Are you willing to work:
Days
Evenings
Overnights
Weekends

Position applying for: *

Educational Background

	School Name / Location	Major	Yrs of Study/Degree
College / Graduate
Vo-Tech / Trade
High School
Others

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.
Company Name:   *

Telephone:     Area Code*   Phone Number*

Address:

Street Address*

Address Line 2*

City*   State*   Zip*

Dates of Employment:    *     *

Starting Pay:   *   Ending Pay:     *

Job Title:   *

Reason for leaving:   *
Company Name:

Telephone:     Area Code   Phone Number

Address:

Street Address

Address Line 2

City   State   Zip

Dates of Employment:

Starting Pay:      Ending Pay:

Job Title:

Reason for leaving:
Company Name:

Telephone:     Area Code   Phone Number

Address:

Street Address

Address Line 2

City   State   Zip

Dates of Employment:

Starting Pay:      Ending Pay:

Job Title:

Reason for leaving:
Was your last name different from your present name during the above-listed jobs?
YES   NO*

If yes, what was your name?

Are you currently employed? YES   NO*

Do you have reliable transportation / the ability to reach multiple clients? YES   NO*
TWO (2) Professional / Personal Reference Check
Reference Full Name   *

Phone    Area Code*   Phone Number*

City   *

State   *

If Professional Reference: Position Held
Reference Full Name   *

Phone    Area Code*   Phone Number*

City   *

State   *

If Professional Reference: Position Held
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and Community Support Agency?*

YESNO
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:
Are you capable of performing the job set forth in the job description?*

YESNO
If you answered No, which job requirement can you not meet?
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED
I certify that the facts in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I,First & Last Name* authorize a complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the payment date of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This employment application shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time
Signature*

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Date*

MonthDayYear
Date
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APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

EMPLOYMENT

TWO (2) Professional / Personal Reference Check

GENERAL