Careers Form

* = Required Information

PERSONAL

Last Name *

First Name *

Middle Name

Date *

Date of Birth*

Email Address*

Street Address *

Home Phone *

City, State, Zip Code

Business Phone

S.S. #

Emergency Contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Newspaper Ad

Agency employee

Other

Expected wages/per hour

Gender

Male

Female

Other

EDUCATION

College

School Name

Location of School

Course of Study Degree/Study

Years of Diploma

Vo-Tech or Trade

School Name

Location of School

Course of Study Degree/Study

Years of Diploma

High School

School Name

Location of School

Course of Study Degree/Study

Years of Diploma

Other

School Name

Location of School

Course of Study Degree/Study

Years of Diploma

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.

Company Name

Telephone

Address

Dates of Employment

From

City

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for leaving

Company Name

Telephone

Address

Dates of Employment

From

City

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for leaving

Company Name

Telephone

Address

Dates of Employment

From

City

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for leaving

Was your last name different from your present name during the above listed jobs?

Yes

What was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance.

Name

Telephone

Fax

Address

Name

Telephone

Fax

Address

Name

Telephone

Fax

Address

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment.

Describe

Are you capable of performing the job set forth in the job description?

Yes

Which job requirement can you not meet?

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

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 hereby give my full permission for the Agency to contact and fully discuss my background and history with persons and entities listed above to give the Agency any and 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 of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Date

Applicant Name

LPN	RN	CNA/PCA/HHA	Sitters
Other