Employment Application Form

APPLICATION FOR EMPLOYMENT
All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
PERSONAL INFORMATION
Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Driver’s License / ID
State
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Have you ever applied for employment with this Agency?
How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
How did you learn of our organization?
Are you willing to work:

Other
Position applying for
Educational Background

Educational Background

Rows	No	Yes
High School
Two year or Associates
Bachelors
Masters
Others

EMPLOYMENT
List the last five years employment history, starting with the most recent employer.
1. Company Name / Telephone / Address / Dates of Employment / Starting Pay / Ending Pay / Job Title and Describe Work Completed / Reason for leaving
2. Company Name / Telephone / Address / Dates of Employment / Starting Pay / Ending Pay / Job Title and Describe Work Completed / Reason for leaving
3. Company Name / Telephone / Address / Dates of Employment / Starting Pay / Ending Pay / Job Title and Describe Work Completed / Reason for leaving
Was your last name different from your present name during the above listed jobs?
If yes, what was your name?
Are you currently employed?
Do you have reliable transportation / the ability to reach multiple clients?
TWO (2) Professional / Personal Reference Check
1. Reference Full Name

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
City
State
If Professional Reference: Position Held
2. Reference Full Name

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
City
State
If Professional Reference: Position Held
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
If yes, describe in full:
Are you capable of performing the job set forth in the job description?
If you answered No, which job requirement can you not meet?
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENTOPERATED
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.
I, authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing such information.
Training and Certifications
Should be Empty:

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

Educational Background

EMPLOYMENT

TWO (2) Professional / Personal Reference Check

GENERAL