TENDER COMPOSURE

First

Middle Initial

Date of Birth

Date

Social Security Number

NPI Number

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Home Address: (If different from local address)

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone Number

Mobile Phone Number

EMail Address

example@example.com

Are you a citizen of the U.S. or do you have a legal right to work in the U.S.?

yesno

Any offer of employment is conditional upon you completing Form I-9 and providing documents Establishing your identity and work authorization.

Are you 19 years of age or older?

yesno

If under 19 years of age, applicant will be required to Submit a birth certificate or work certificate as required by State or Federal law.

Have you ever pleaded "guilty","no - contest "or been convicted of a crime?

yesno

If Yes When and Where

If Yes please provide details

Type of employment Desired?

Full-TimePart-Time

Date Available To Start

Date

How many hours per week would you like to work?

How were you referred to us

How far do you live from the primary service location

What days and hours are you available to work?

Education

Are you presently enrolled in school? If yes, please provide name and address of the school you are attending:

School Name and Address

Type Of Degree or Program

Expected Completion Date

Date

Did you successfully complete high school and receive a diploma?

yesno

If you did not complete high school, do you have a high school equivalency diploma (GED)?

yesno

Name and address of last school attended:

School Name and Address

From

To

Date Of Degree

Date

Major

List any other education degrees special skills qualifications or certifications

Employment History

Company Name and Address

Job Title

Company Phone Number

Supervisor Name

Date of Employment

From

To

Last Pay Rate

Reason For Leaving If Applicable

May We Contact This Employer?

YesNo

I have been given the opportunity to read this employment application thoroughly and ask questions. My signature on this form attests that all information I provided to the employer is true and complete. I understand that any false or misleading information, or significant omission, may disqualify me from consideration for employment; or if hired, may lead to my dismissal if discovered at a later date. I understand that consideration for employment may depend upon results from my references and potential background check. I grant Tender Composure, permission to obtain personal investigative reports on me, including, but not limited to statements made in this application or resume, character information, general reputation, education, licensing or certifications. I authorize and release from legal liability, any individual, school, institution (s), or employer providing information or opinion with respect to potential employment with this employer. I understand that employment is contingent upon providing authentic proof of identity and employment eligibility in the United States, and for some positions passing a drug and alcohol test. I agree to be possibly submitted to drug testing as part of the hiring process with the employer, and understand that I will receive separate notice and release before testing. I agree to immediately notify Tender Composure if I should be convicted of a felony, or any crime involving dishonesty, breach of confidentiality, controlled substances, sexual misconduct, abuse or violence while my job application is pending, or if hired, during employment. I acknowledge that employment with this employer would beat-will and that this application for employment does not create an employment contract or promise of employment.

Signature of Applicant

Date