Heart & Hands Home Health LLC APPLICATION FOR EMPLOYMENT
PERSONAL INFORMATION
DATE
/
Month
/
Day
Year
Date
Name
First Name
Middle Name
Last Name
SOCIAL SECURITY
PRESENT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PRESENT ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
ARE YOU 18 YEARS OR OLDER?
Yes
No
ARE YOU EITHER A U.S. CITIZEN OR AN ALIEN AUTHORIZED TO WORK IN THE UNITED STATES?
Yes
No
EMPLOYMENT DESIRED
REFERRED BY
POSITION
SALARY DESIRED
/
Month
/
Day
Year
Date
ARE YOU EMPLOYED
IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER
EVER APPLIED TO THIS COMPANY BEFORE
WHERE
WHEN
EDUCATION
NAME AND LOCATION OF SCHOOL
NO. OF YEARS ATTENDED
*DID YOU GRADUATE?
SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS OR CORRESPONDENCE SCHOOL
GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
SPECIAL SKILLS
CERTIFICATIONS (CPR, 1ST AID, ETC)
ACTIVITIES: (CIVIC, ATHLETIC, ETC)
EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.
ARE YOU A LICENSED DRIVER?
Yes
No
DRIVER'S LICENSE NO.
STATE OF LICENSE
HAVE YOU EVER BEEN CHARGED WITH OR ARRESTED FOR ANY CRIMINAL OFFENSE OTHER THAN A MINOR MOTOR VEHICLE VIOLATION? INCLUDES OFFENSES WHICH HAVE BEEN DISMISSED, DISCHARGED, OR NOLLE PROSEQUI. (ALL ARRESTS AND CHARGES MUST BE DISCLOSED AND EXPLAINED ON AN ATTACHED SHEET.)
Yes
No
Explain
DO YOU HAVE A HISTORY OF SUBSTANCE ABUSE? (IF YES, EXPLAINED ON AN ATTACHED SHEET.)
Yes
No
Explain
US MILITARY OR NAVAL SERVICE
RANK
PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES
FORMER EMPLOYERS
(LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
DATE MONTH AND YEAR
From (DATE MONTH AND YEAR )
To(DATE MONTH AND YEAR )
NAME AND ADDRESS OF EMPLOYER
SALARY
POSITION
REASON FOR LEAVING
.
.
.
.
REFERENCES:
GIVE THE NAMES OF TWO EMPLOYERS AND 1 PERSON NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEASE ONE YEAR
NAME
ADDRESS
BUSINESS
YEARS ACQUAINTED
1
2
3
IN CASE OF EMERGENCY NOTIFY
NAME
ADDRESS
PHONE NO.
RELATIONSHIP
"I CERTIFY THAT THE FACTS CONTAINED 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 AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM YOUR OBTAINING THIS INFORMATION.
Date
-
Month
-
Day
Year
Date
SIGNATURE
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