* = Required Information

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.
APPLICANT

Last Name                First                Middle * Date *
Street Address * Home Phone *
City                State                Zip Code * Business Phone *
Social Security Number *
Emergency contact (person not living with you)
Have you ever applied for employment with this Agency? YesNo
How many hours a week are you available for work?
Are you legally eligible for employment in the United States? YesNo
How did you learn of our organization?
Newspaper Ad Friend Other
Are you willing to work on evenings/weekends: If so, what hours?

Position applying for

EDUCATION
School Name of Degree/Diploma Location of School Course of Study Years
College
Vo-Tech or Trade
High School
Other
EMPLOYMENT
List the last five years employment history, starting with the most recent employer.
1. Company Name Telephone
Address    
Dates of Employment

From To
City State Zip Code Starting Pay
Job Title and describe your work

Reason for leaving

2. Company Name Telephone
Address    
Dates of Employment

From To
City State Zip Code Starting Pay
Job Title and describe your work

Reason for leaving

3. Company Name Telephone
Address    
Dates of Employment

From To
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? YesNo
If Yes, what was your name?
Are you currently employed? YesNo
Do you have reliable transportation? YesNo
PROFESSIONAL REFERENCES
Persons who can furnish information about job performance
1. Name Telephone
Address    
 
2. Name Telephone
Address    
 
3. Name Telephone
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?
YesNo
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?
YesNo
If you answered No, 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 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 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.


* Security Code