*First Name:

Middle: *Last:

*Present Address:

*Street:

*City: *State: *Zip:

*How long have you lived at this address?

Pevious Address:

Street

City: State: Zip:

How long had you lived at this address?

*Home Phone:

( ) - Cell Phone: ( ) -

Work Phone:

( ) - *Email Address:

*Are any of your relatives presently employed with the company or its divisions? Yes No

If Yes, name of relative:

*Have you ever worked for the company or its divisions before? Yes No

If Yes, where: Approximate Date (mm/yyyy):

*Have you ever applied for the company or its divisions before? Yes No

If Yes, where: Approximate Date (mm/yyyy):

*How were you referred?

*Are you 18 years of age or older? Yes No

  If No, please state your age: Can you supply working papers? Yes No

*Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? Yes No

*Have you ever been convicted of a crime or violation other than a minor traffic infraction? (A conviction record will not necessarily be a bar to employment. Factors such as job relations, age and time of the offense, seriousness and nature of violation and rehabilitation will be taken into account) Yes No

  If yes, please explain:
 

*Have you ever been discharged from any employment or asked to resign? Yes No

  If yes, please explain:
 

*Drivers License: Yes No   *Car Available: Yes No

*Dependable Transportation: Yes No

PHYSICAL / MEDICAL

Recent Physical Exam Date (mm/yyyy):

*Are special accommodations needed for you to be able to perform
the essential functions of the job? Yes No

  If yes, please explain:
 

*Date available to start (mm/dd):

*Wage expected:

Note: Work schedules are based upon the needs of the
business and may be subject to change on a weekly basis.

Please list all past employment, beginning with the most recent employment.

Employer 1:

  Company Name: Type of Business:

  Address: City: State: zip:

  Job Title: Describe Your Job Duties:

  Period Worked: From (mmyyyy): To (mmyyyy):

  Starting Salary: $ Ending Salary: $

  Supervisor's Name & Title: Telephone: () -

  Reason for Leaving: May we contact employer? Yes No

 
Employer 2:

  Company Name: Type of Business:

  Address: City: State: zip:

  Job Title: Describe Your Job Duties:

  Period Worked: From (mmyyyy): To (mmyyyy):

  Starting Salary: $ Ending Salary: $

  Supervisor's Name & Title: Telephone: () -

  Reason for Leaving: May we contact employer? Yes No

 
Employer 3:

  Company Name: Type of Business:

  Address: City: State: zip:

  Job Title: Describe Your Job Duties:

  Period Worked: From (mmyyyy): To (mmyyyy):

  Starting Salary: $ Ending Salary: $

  Supervisor's Name & Title: Telephone: () -

  Reason for Leaving: May we contact employer? Yes No

 
Employer 4:

  Company Name: Type of Business:

  Address: City: State: zip:

  Job Title: Describe Your Job Duties:

  Period Worked: From (mmyyyy): To (mmyyyy):

  Starting Salary: $ Ending Salary: $

  Supervisor's Name & Title: Telephone: () -

  Reason for Leaving: May we contact employer? Yes No

High School:

Address:

Years Completed: Year Graduated (yyyy):

College:

Address:

Years Completed: Year Graduated (yyyy):

Major Subject: Degree:

College:

Address:

Years Completed: Year Graduated (yyyy):

Major Subject: Degree:

Graduate School:

Address:

Years Completed: Year Graduated (yyyy):

Major Subject: Degree:

Business/Trade/Other:

Address:

Years Completed: Year Graduated (yyyy):

Major Subject: Degree:

*Are you a certified HHA/PCA or CNA? Yes No

License #:

Date of Certification (mm/yyyy):

State:

Expiration Date (mm/yyyy):

Name of School/Agency Issuing Certificate:

Type(s):
Select all that apply

RN LPN CNA HHA PCA Training Course PT OT ST RT SW

Specialized Training/Experience: Pediatric: Yes No   Developmentally Disabled: Yes No

Do you speak a foreign language? Yes No   Languages Spoken:

Additional Experience or Qualifications:
List any other experience, skills or other qualifications including hobbies, which you believe should be considered in evaluating your qualifications for employment. (Please indicate any prior military service which you would like considered in connection with your application for employment.)

*Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with the company? Yes No

  If yes, please explain:
 

Please give two references, not related to you.
For example: a doctor, dentist, lawyer, pastor, etc.
No personal references.

Reference 1:

Name:

Telephone: () -

Address:

Reference 2:

Name:

Telephone: () -

Address:

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President or Executive Vice President, or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.

*I understand and agree to the above.

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