Personal
First Name:
*
Last Name:
*
Street Address:
*
Address Line 2:
City:
*
State:
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
ZIP Code:
*
Phone Number:
*
Email Address:
*
Have you ever applied for employment with us?
*
Yes
No
If you have applied previously, please indicate the date of your prior application:
Social Security Number:
Position Desired:
*
Pay Expected:
*
What hours are you available for work?
*
When will you be available to begin work?
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Locations you are available to work (e.g., counties, cities, etc.):
*
Are you eligible for employment in the United States?
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Yes
No
Have you ever been convicted of a crime?
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Yes
No
If yes, when?
Education
High school name and location:
*
High school - Number of years completed:
*
High school graduation date:
College name and location:
College course of study:
College - Number of years completed:
College graduation date:
Business/Trade/Technical School name and location:
Business/Trade/Technical School course of study:
Business/Trade/Technical School - Number of years completed:
Business/Trade/Technical School graduation date:
Professional Memberships
List any memberships in professional or civic organizations (exclude those which may disclose your race, color, religion or national origin):
Employment History
Employer 1 Name:
*
Employer 1 Address:
*
Employer 1 Telephone Number:
*
Employer 1 - Beginning employment date:
*
Employer 1 - Ending employment date:
Employer 1 - Name of supervisor:
*
Employer 1 - Job Title and describe your work:
*
Employer 1 - Weekly pay - start:
*
Employer 1 - Weekly pay - last:
*
Employer 1 - Reason for leaving:
*
May we contact Employer 1?
*
Yes
No
Employer 2 Name:
Employer 2 Address:
Employer 2 Telephone Number:
Employer 2 - Beginning employment date:
Employer 2 - Ending employment date:
Employer 2 - Name of supervisor:
Employer 2 - Job title and describe your work:
Employer 2 - Weekly pay - start:
Employer 2 - Weekly pay - last:
Employer 2 - Reason for leaving:
May we contact Employer 2?
Yes
No
Employer 3 Name:
Employer 3 Address:
Employer 3 Telephone Number:
Employer 3 - Beginning employment date:
Employer 3 - Ending employment date:
Employer 3 - Name of supervisor:
Employer 3 - Job title and describe your work:
Employer 3 - Weekly pay - start:
Employer 3 - Weekly pay - last:
Employer 3 - Reason for leaving:
May we contact Employer 3?
Yes
No
Attestations
I attest that the information provided in this Application for Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. If you decide to engage an investigative consumer-reporting agency to report on my credit and personal history, I authorize you to do so. If a report is obtained, you must provide, at my request, the name of the agency so I may obtain from them the nature and substance of the information contained in the report.
*
Yes
No
I authorize Christian Community Homecare to obtain all necessary background information from previous employers.
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Yes
No
Personal References
Please do not include relatives. List three individuals familiar with your background and workability. If we experience difficulty in contacting the individuals listed, we will call you for additional references.
Personal Reference Name - 1:
*
Personal Reference Telephone Number - 1:
*
How do you know this person?
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Number of years known:
*
Personal Reference Name - 2:
*
Personal Reference Telephone Number - 2:
*
How do you know this person?
*
Number of years known:
*
Personal Reference Name - 3:
*
Personal Reference Telephone Number - 3:
*
How do you know this person?
*
Number of years known:
*
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