Application for Employment

Full Name

First NameMiddle NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityStateZip CodeCountry

Position Applied For

Are you 18 years of age or older?

Are you legally eligible to work?

Relevant Certifications or Licenses (e.g., CNA, RN, CPR)

Years of Experience in Home Care or Medical Field

Do you have a valid driver's license?

Driver’s License Number

State of License

Class of License

Have you had your driver’s license suspended or revoked in the last 3 years?

If yes, give details:

Have you ever been convicted of any law violation (except a minor traffic violation)?

If yes, give details:

A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.)

Describe your relevant work experience

Availability (days/hours)

Upload Resume (PDF, DOC, or DOCX)

PLEASE READ CAREFULLY AND AGREE BEFORE SIGNING AND SUBMITTING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organization from any legal liability in making such statements.I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required.I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read, understand, and by my signature consent to these statements.

Signature

Date Signed and Submitted

Date

Application for Employment

Road Opener Group is an Equal Opportunity Employer