HHA employment application

An Equal Opportunity Employer. Reasonable accommodation under the Americans with Disabilities Act will be provided as required by law.

Name

Full First NameMiddle InitialLast Name

Social Security Number

Address

Street Address

Street Address Line 2

CityState

Zip Code

If hired, can you provide evidence of legal eligibility to work in the

Format: (000) 000-0000.

Have you lived at this address for 2 years

Have you lived at this address for 2 years?In no, please provide another address.

In no, please provide another address

Any offer of employment is conditioned upon completing form I9 and providing the appropriate documents for identity and work

Have you ever been convicted of a felony, or a misdemeanor involving any violent act, use or possession of a weapon, or act of dishonesty for which the record has not been sealed or

expunged, or do you have such a case pending?

If yes, when

If yes, location of case

Date you can begin work

Date

Birth date

If under 18 years of age, you will be required to submit a birth certificate or work certificate as required by federal law

Name of high school attended

City State

Graduate

GED

Name of college or technical school

Name of college or technical school-City & State-

City State

Graduate

Degree

Major

Are you presently enrolled in school

Are you presently enrolled in school-If yes, give name & address of school and expected degree date-

If yes give name address of school and expected degree date

Date

Do you have a current 2 Step TB test done in the past year?

Date of test

Date

Have you ever had a positive TB skin test

Total hours per week you are available to work: _________________________

Do you have a current driver's license? Do you have reliable transportation? _____

Do you have a current drivers license

Do you have reliable transportation

Your Employment History List names of employers with present or last employer listed first

Address

Name of Employer

Duties

Job Title

Duties: Dates of Employment: From:

City State Zip Code

From

To

Hourly pay or salary: Starting pay: Reason for Leaving:

Starting pay

Hourly pay or salary

Reason for Leaving

Ending pay

Supervisor: Telephone

Format: (000) 000-0000.

Address

Name of Employer

Job Title

Duties: Dates of Employment: From:

Duties

From

Dates of Employment

Date

City State Zip Code

To

Hourly pay or salary: Starting pay: Reason for Leaving:

Starting pay

Hourly pay or salary

Reason for Leaving

Ending pay

Telephone

Format: (000) 000-0000.

Address

Name of Employer

Job Title Duties

City State Zip Code

From

To

Hourly pay or salary: Starting pay: Reason for Leaving:

Starting pay

Hourly pay or salary

Reason for Leaving

Ending pay

Supervisor: Telephone

Format: (000) 000-0000.

CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

I certify that all of the information provided in this employment application are true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, including a criminal background and credit history check. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date.

I understand and acknowledge that unless otherwise defined by applicable law or written agreement with North Side Christian Health Center any employment relationship with the North Side Christian Health Center is considered "employment at will." This means the Employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause, and with or without advance notice.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision.I release such persons and organizations from any legal liability in making such statements.

Signature

Date

Email

example@example.com