AXIS Application revised

AXIS Application for Employment (AA/ EOE)
Today's date

MonthDayYear
E-mail*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Driver's License Number*
Is your driver's license current and valid?

YesNo
State Issued
Are you over 18 years old?*

YesNo
Are you a U.S. Citizen?*

YesNo
If you are not a citizen, do you have a legal right to work in the U.S.?

YesNo
Were you referred by someone who works for AXIS?

YesNo
If yes, who? This person may eligible for a referral bonus).
Position you are applying for:
Date you are available:

MonthDayYear
Are you looking for full time or part time work?

Full timePart time
Availability

DaysEveningsOvernightsWeekends
Availability

DaysEveningsOvernightsWeekends
Describe your experience supporting people who have intellectual or developmental disabilities:
Education and training
High School name and address
College or trade school name and address:
Degree or diploma earned:
Other education or training:
Professional licenses (include type, State, number and year):
Are you a trained medication administrator?

YesNo
Do you have a current CPR certification?

YesNo
Do you have a current First Aid certification?

YesNo
Employment History and References

Please provide information about your two most recent or most relevant employers. You must provide an email address for the person we may contact to verify the information. Interviews will not be scheduled until employment verifications are made.
Employer 1: Company, city, state
Employer 1 email
Employer 1 phone*

Area CodePhone Number
Position held
Start and end dates
Status

Full timePart time
General duties
Employer 2: Company, city, state
Employer 2 email
Employer 2 phone*

Area CodePhone Number
Position held
Start and end dates
Status

Full timePart time
General duties
Regarding reference checks: I authorize AXIS to investigate all information relevant to my fitness for employment with AXIS. I release AXIS and all parties from any liability for damage requested, exchanged or provided to AXIS.
Check box to verify you have read and understand the release of information statement

Yes
Emergency Contact

Who should we contact if you have an emergency?
Emergency Contact Person's Name*
Emergency Contact Phone Number*

Area CodePhone Number
I authorize AXIS to investigate all information relevant to my fitness for employment with AXIS. Background studies, including photographing and fingerprinting are required after an employment offer is made. I release AXIS and all parties from any liability for damages related to information requested, exchanged or provided to AXIS.
By checking this box, you verify that you have read and understood this statement.*

Yes
I certify that the information in this application is true and complete to the best of my knowledge. I understand that false statements or omissions shall be grounds for my dismissal if hired or refusal of employment. I understand that no employment with AXIS is contractual but rather is 'at will' which means that either AXIS or I may terminate the employment relationship at any time, without notice or for any reason not prohibited by law. By checking the box below, you verify that you have read and understood this statement.
By checking this box, you verify that you have read and understood this statement.*

Yes
Name

First NameLast Name
Should be Empty:

AXIS Application for Employment (AA/ EOE)

Education and training

Employment History and References

Emergency Contact