APPLICATION FOR EMPLOYMENT

Keagan’s Residential Care Homes, LLC is an equal opportunity employer that does not discriminate in employment with regard to race, color, religion, national origin, citizenship status, ancestry, age, sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service or any other characteristic protected by law.

Incomplete information could disqualify you from further consideration. Please complete all fields.

Name

Date

Address

E-mail Address

example@example.com

Home Phone

Mobile Phone

Are you eligible to work in the U.S?

YesNo

Are you at least 18 years or older? (If no, you may be required to provide authorization to work.)

YesNo

Have you ever been convicted of a felony or misdemeanor?

YesNo

If yes, please explain

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

Have you ever been terminated from employment or asked to resign by an employer?

YesNo

If yes, please provide company names and details

Are you able to work any shift?

YesNo

If no, explain:

Can you work overtime, including weekends?

YesNo

Are you able to perform the essential functions of the job for which you are applying, with orwithout a reasonable accommodation?

YesNo

Date you can start

Hourly rate/Salary desired

Position desired

Are you currently employed?

If so may we inquire of your present employer?

How did you hear about us?

EDUCATION

	Name and location of school	Degree Received	Subjects studied/Major
High School
College or University
Trade, Business or Correspondence School

EMPLOYMENT HISTORY Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.

From

To

Employer Name

Job Title

Phone

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

Reason for leaving

From

To

Employer

Job Title

Phone

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

Reason for leaving

From

To

Employer

Job Title

Phone

Address

Immediate supervisor and title

Summarize the nature of work performed and job responsibilities

Reason for leaving

Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain.

REFERENCES

Give the names of three persons not related to you, whom you have known at least three (3) years.

Name

	Address, Phone, Email	Company	Years Acquainted
1
2
3

Please read carefully before signing.I understand that neither the completion of this application nor any other part of myconsideration for employment establishes any obligation for Keagan’s Care Residential Homes,LLC to hire me. If I am hired, I understand that either Keagan’s Care Residential Homes, LLC orI can terminate my employment at any time and for any reason, with or without cause andwithout prior notice. I understand that no representative of Keagan’s Care Residential Homes,LLC has the authority to make any assurance to the contrary.I attest with my signature below that I have given Keagan’s Care Residential Homes, LLC trueand complete information on this application. No requested information has been concealed. Iauthorize Keagan’s Care Residential Homes, LLC to contact references provided foremployment reference checks. If any information I have provided is untrue, or if I haveconcealed material information, I understand that this will constitute cause for the denial ofemployment or immediate dismissal.

THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE ABOVE

Date

SIgnature

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

EMPLOYMENT DESIRED

REFERRAL SOURCE