HE Employment Application

Date

Name (first, middle, last)*

Address (street, city, state, zip code)

Mobile Telephone ()*

Format: (000) 000-0000.

Email Address*

example@example.com

Home Telephone ( )

Format: (000) 000-0000.

Are there other names under which you have worked or attended school?

YesNo

If yes, please list for reference checking purposes.

example@example.com

Are you legally authorized to work in the U.S.?*

YesNo

Are you at least 18 years old?*

YesNo

If not, your employment will be subject to verification that you meet state/federal minimum age requirements for the type of work you are applying for and have obtained a valid work permit.

Have you ever applied at Healing Elements before?*

YesNo

If yes, when

Have you ever worked at Healing Elements before?*

YesNo

If yes, when

Position you are Applying for*

Salary Preference*

Hours per week desired*

When are you available to start working?*

How were you referred to the company?

What days and hours are you not available to work?*

Have you been convicted of, or pleaded no contest to a felony within the last five years?

School Attended - High School (Name & Location)

# of Years attended/ Major Subjects

Diploma or Degree Received

YesNo

College attended (Name & Location)

# of Years attended/ Major Subjects

Diploma or Degree Received

YesNo

Technical School - (Name & Location)

# of Years attended / Major Subjects

Diploma or Degree Received

YesNo

Other type of School you may have attended

Courses, Certifications, or Certificates

Are you licensed for the job for which you are applying?*

YesNo

License Number

State Issued

Expiration Date

Employment History-Starting with most recent

Name of Employer

Phone Number

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

Address

Job Title

Employment Dates (month and year)

Date you started at this Job

Date you ended at this Job

Name of Immediate Supervisor

Description of Duties

Reason for Leaving

If currently employed, may we contact them for a reference?

YesNo

Name of Employer

Telephone

Address

Job Title

Employment Dates (month and year)

Date you started this job

Date you ended this Job

Name of Immediate Supervisor

Description of Duties

Reason for Leaving

Name of Employer

Telephone

Address

Job Title

Employment Dates (month and year)

Date you started at this Job

Date you ended at this Job

Name of Immediate Supervisor

Description of Duties

Reason for Leaving

Name of Employer

Telephone

Address

Job Title

Employment Dates (month and year)

Date you started at this Job

Date you ended at this job

Name of Immediate Supervisor

Description of Duties

Reason for Leaving

References (List individuals familiar with your job qualifications (no relatives or personal friends)

Name

Telephone

Format: (000) 000-0000.

Email Address

example@example.com

Address

Relationship

How long have you know them?

Name

Telephone ( )

Format: (000) 000-0000.

Email Address

example@example.com

Address

Relationship

How long have you known them?

Name

Telephone ( )

Format: (000) 000-0000.

Email Address

example@example.com

Address

Relationship

How long have you known them?

Please Read Carefully Before Signing This Form

1. I certify that all of the information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired.

2. I authorize the verification of any or all information that is listed above.

Signed by*

Date

EMPLOYMENT APPLICATION