Job Application

Full Name*

First NameMiddle NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Email Address*

Social Security Number*

No dashes

Driver License Number*

Birthday*

Date

Are you willing to work overnight hours?*

YesNo

Best Time To Contact *

Applying for Position*

Which type of employment are you looking for?*

Full TimePart TimePRNAnytime

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis?(You may be required to provide documentation).*

YesNo

Availability *

Are you willing to work weekends?*

YesNo

Do you have a valid drivers license?*

YesNo

Do you have 6 points or more on your BMV record?*

YesNo

Have you ever been convicted of a felony or misdemeanor?This will not necessarily affect your application.*

YesNo

If yes, please describe date and details of condition.

Position(s) applying forMay choose more than one*

Have you ever applied for employment here?*

YesNo

If Yes, When?

Were you referred by anyone? If YES, whom?

Are you presently employed?*

YesNo

May we contact you present employer?*

YesNo

Are you willing to travel?*

YesNo

Start date*

MonthDayYear

Desired Salary *

Diploma Type*

GEDHigh School Diploma

High School Name*

Year of Completion *

College Name

Degree Earned

YesNoIn progress

Field of Study

Post College Name

Degree Earned

YesNoIn progress

Field of Study

Other Tranning

Certifications: May choose more than one

Company Name*

Most Recent Employment

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor Name *

First NameLast Name

Supervisor Phone Number*

Area CodePhone Number

Start Date*

Date

End Date*

Date

Starting Position*

Ending Position*

Most Recent Employment

Starting Wage*

Ending Wage*

Reason for Leaving *

Most Recent Employment

Responsibilities *

Most Recent Employment

Company Name*

Most Recent Employment

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor Name *

First NameLast Name

Supervisor Phone Number*

Area CodePhone Number

Starting Wage*

Ending Wage*

Starting Position*

Ending Position*

Most Recent Employment

Start Date*

Date

End Date*

Date

Reason for Leaving *

Most Recent Employment

Responsibilities *

Most Recent Employment

Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Email Required*

example@example.com

Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Email Required *

example@example.com

Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Email Required *

example@example.com

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You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, sexual orientation, marital status, veteran status or any other protected status.

Please Read Before Signing

I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. If employed, any misstatements or omissions of fact on this application may result in my dismissal. I agree that neither the acceptance of this application, an offer, nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, policies and procedures manuals, and the like as they may exist from time to time shall serve to create an actual or implied contract of employment.

I authorize my previous employers, schools or persons listed as references to give any information regarding employment or educational record. I agree that Different Abilities Transportation and Care LLC. and my previous employers will not be held liable in any respect if a job offer is not extended, is withdrawn or employment is terminated because of false statements, omissions or answers made my myself on this application. In the event of any employment with Different Abilities Transportation and Care LLC. I will comply with all policies and procedures as set forth by the company in any communication distributed to the employees. I fully understand that Different Abilities Transportation and Care LLC. may change or revise its policies and procedures without advanced notice and that such change may include reduction in hours, salary or benefits. In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment.

For the purpose of my possible employment, I authorize Different Abilities Transportation and Care LLC to use my Social Security number and Drivers Liscense number for employment screenings only. Also, to order a consumer reports to make a thorough investigation into my background which may include my: Academic Records, Criminal Record, Employment Record, Financial and Credit Information, Military Service Record, Physical Health Record, Psychological Status Any/All Social Media Accounts, and Reputation and Character Record.

I understand that information obtained from this background investigation may constitute a basis for denial of my employment. I also understand that any information obtained from this background investigation will be used solely for the purpose it was intended and will not be disseminated outside of Different Abilities Transportation and Care LLC. I understand that employment at this company is “at will”, which means that either I or Different Abilities Transportation and Care LLC can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements

Signature*

When signing below I verify that I am aware that Different Abilities will use my Social Security Number and Drivers Liscense number to run employment checks.I hereby acknowledge that I have read the terms and conditions.

Job Application

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