Application for Employment
Clean Hands Pure Hearts
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 Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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6/2/26, 6:56 PM
Application for Employment
City
State / Province
Postal / Zip Code
Home Phone Number *
*
Format: (000) 000-0000.
Social Security Number *
*
Please enter a valid phone number.
Driver's License / ID *
*
State *
*
Date of Birth *
*
-
Month
-
Day
Year
Date
Email Address
example@example.com
Date
Have you ever applied for employment with this Agency?
YES
NO
How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
YES
NO
How did you learn of our organization?
Newspaper Ad
Agency employee
Other
Are you willing to work:
Evenings
Weekends
Position applying for:
Educational Background
Educational Background
Rows
School Name / Location
Major
Yrs of Study/Degree
College / Graduate
Vo-Tech / Trade
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EMPLOYMENT
List the last five years employment history, starting with the most recent employer.
1. Company Name:
Telephone:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
mm-dd-yyyy
-
Month
-
Day
Year
Date
mm-dd-yyyy
-
Month
-
Day
Year
Date
Starting Pay:
Ending Pay:
Job Title and Describe Work Completed:
Reason for leaving:
2. Company Name:
Telephone:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
mm-dd-yyyy
-
Month
-
Day
Year
Date
mm-dd-yyyy
-
Month
-
Day
Year
Date
Starting Pay:
Ending Pay:
Job Title and Describe Work Completed:
Reason for leaving:
3. Company Name:
Telephone:
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
mm-dd-yyyy
-
Month
-
Day
Year
Date
mm-dd-yyyy
-
Month
-
Day
Year
Date
Starting Pay:
Ending Pay:
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Application for Employment
Job Title and Describe Work Completed:
Reason for leaving:
Was your last name different from your present name during the above listed jobs?
YES
NO
If yes, what was your name?
Are you currently employed?
YES
NO
Do you have reliable transportation / the ability to reach multiple clients?
YES
NO
TWO (2) Professional / Personal Reference Check
1. Reference Full Name
*
Phone
*
City
*
State
*
If Professional Reference: Position Held
2. Reference Full Name
*
Type option 1
Type option 2
Phone
*
City
*
State
*
If Professional Reference: Position Held
GENERAL
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Application for Employment
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
YES
NO
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:
Are you capable of performing the job set forth in the job description?
YES
NO
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
6/2/26, 6:56 PM
Application for Employment
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 my result from furnishing the same to the Agency.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time
Signature
*
Date
*
-
Month
-
Day
Year
Date
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