Employment Application Form

Employment Application Form:
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Preferred method of contact*
Birth Date

MonthDayYear
SSN
Social Security Number
US Citizen?*

YesNo
Permitted to work in US?*

YesNo
US Veteran?

YesNo
Do you have a valid drivers License

YesNo
Have you been convicted of a Felony?

YesNo
Preferred Languages
If "Yes" Please explain
List details of any convictions
Salary Desired
Employment Desired:
Position Applying For
Date You Can Start

MonthDayYear
Have You Worked Here Before?

YesNo
If "Yes" When and what Position?
Highest Level of Education:
Choose one*
Number of Years Attended
Graduated?

Yes
Area of Study/Degree
Skills/Qualifications:
Special Skills, Training, and Experience
List anything relevant to position
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
Supervisor Name
May We Contact?

YesNo
Phone Number

Area CodePhone Number
Previous Employment:
Previous Employer 1
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Supervisor Name
May We Contact?

YesNo
Phone Number

Area CodePhone Number
Previous Employer 2
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Supervisor Name
May We Contact?

YesNo
Phone Number

Area CodePhone Number
References:

(Non Family Related)
Reference 1*
Name of Reference
Relationship*
Years Known*
Phone*
Email*
Reference 2*
Name of Reference
Relationship*
Years Known*
Phone*
Email*
Reference 3*
Name of Reference
Relationship*
Years Known*
Phone*
Email*
I understand that incomplete applications may not be considered. I certify that all information provided is true and complete to the best of my knowledge and understand that any false or misleading information may result in disqualification or termination at any time.

I understand that employment is contingent upon satisfactory background and required regulatory checks. I authorize Milestone Care Solutions, LLC to verify the information provided and release all parties from liability related to such verification.

I understand that this application does not create an employment contract, that employment is at-will, and that either party may terminate employment at any time, with or without cause or notice. Completing this application does not guarantee employment. If hired, I agree to comply with all Agency policies, which may be revised at any time.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTOOD THIS STATEMENT.
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Employment Application Form:

Personal Information:

Employment Desired:

Highest Level of Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

References: