Dimensions Of Care
Employment Application
Applicant Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Social Security Number
*
Drivers License # and State
Desired Salary $
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the US?
Yes
No
Have you ever worked for this company before?
Yes
No
If yes, when?
Do you consent to a pre-employment criminal record check?
Yes
No
Do you consent to a closed records record check?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, explain:
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Education
High School You Attended:
Name
Address
What years Did you attend?
Example 2004-2008
Do you graduate?
Yes
No
Did you receive your diploma?
Yes
No
College You Attended:
Name
Address
What years Did you attend?
Example 2004-2008
Do you graduate?
Yes
No
Degree
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Please List 3 Professional References
Full Name
Relationship
Company Name
Phone Number
Address
Full Name
Relationship
Company Name
Phone Number
Address
Full Name
Relationship
Company Name
Phone Number
Address
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Previous Employment
Company
Phone Number
address
Job Title
Name
Starting Pay
Ending Pay
Responsibilities at your previous job.
Time of employment
Starting Date
Ending Date
Reason for leaving
May we contact your previous supervisor for a reference?
Yes
No
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Military Service
Branch
Dates Served
Dates (08/2000-12/2006)
Rank at discharge
Type of Discharge
If other than honorable, explain:
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Disclaimer and signature
I certify that my answers are true and complete to the best of my knowledge
*
Yes
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
*
Yes
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: