APPLICATION FOR EMPLOYMENT

 

 

Please Print:                                                                               Date:_____________________________________

 

Position(s) applied for: _______________________________________________________________________

 

Name: ____________________________________________________________________________________

                        (LAST)                                                                              (FIRST)                                                           (MI)

 

Mailing Address: ___________________________________________________________________________ 

                                                (STREET)                                                           (CITY)                                             (STATE)                                           (ZIP CODE)

 

Home Phone: ____________________________________  Cell Phone: ______________________________

 

Drivers License:____________________________________________________________________________

                                    (STATE)                                                                              (NUMBER)                                                                           (EXP DATE)

 

 

How did you hear about us? 

0 Relative   0 Employment Agency    0 Newspaper 0 Internet   0 Friend   0 Walk-In   0 Other

Have you filled out an application here within the last year? 0 No  

           0 Yes- If yes,  Date of Application____________

If you are under 18 years old, can you furnish a work permit? 0 No  0 Yes

If hired, can you provide documentation to show you are legally eligible to work in the U.S.? 0 Yes

0 No (Employment is contingent upon proof of employment verification.)

 

WORK AVAILABILITY

Are you employed now? 0 No 0 Yes   If yes, may we contact your current employer? 0 Yes  0 No

Are you available to work:

0 Block Shifts  0 Shorter Shifts

INTERVIEW:

 

____Yes  __________ With Whom

 

_____ No- Why Not ___________

 

__________ Salary / Hour
 
Shifts Available:

0 7am-3pm      0 3pm-11pm    011pm-7am     0 9am-5pm

Are you interested in being a live-in 0 Yes      0 No

 

Salary Expected _________________ per ____________       

 

 

 

 

CLINICAL APPLICANT ONLY

Professional License Type: ______________________________State_________________________________

                                    Number: __________________________Exp Date:______________________________

                                    Type:_____________________________ Awarded by:___________________________

 

Discuss any special skills and qualifications you possess:

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

 

CLERICAL APPLICATION ONLY

Check the Areas in which you have experience:

0  Computer 0 Typewriter  0 Phone System    0 Photocopy Machine   0 Fax Machine

 

Computer Software: _________________________________________________________________________

 

Discuss any Skills and Qualification you Possess: __________________________________________________

 

HOME CARE AIDE APPLICATION ONLY

 Are you certified as a Home Care Aide? 0 Yes    0 No

If yes, give place and date of certification: ________________________________________________________

(Proof of certification is required)

 

Are you Certified Nursing Assistant or NursesÕ Aide? 0 Yes   0 No

If yes, give place and date of certification: ________________________________________________________

 

Give Current State License Number: ___________________________________________________________

 

EDUCATION (If required of position)

 

School Name

Address

# Years Attended

Degree

Major

High School

 

 

 

 

 

 

 

College

 

 

 

 

 

 

 

Graduate

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

Did you graduate: 0 High School        0 College        0 Graduate      0 Other

 

State any additional information you feel may be helpful to us in considering your application.

 

__________________________________________________________________________________________

 

                                   

NOTE TO APPLICANTS: Do not answer this question unless you have been informed about the requirements of the job in which you are applying.

 

 Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the essential functions involved in the job or occupation for which you have applied? 0 Yes   0 No

( A description of the activities involved in such a job or occupation is attached)

 

SEALED RECORD NOTICE

An Applicant for employment with a sealed record on file with the commissioner or probation may answer ÒNo RecordÓ with respect to any injury herein relative to prior arrests, criminal court appearances or convictions.  In addition, any applicant for employment may answer ÒNo RecordÓ with respect to any injury relative to prior arrests, court appearances, and adjustments in all cases of delinquency or as a child in need of services which does not result in a complaint transfer to the superior court for criminal prosecution.

Within the past five years, have you been convicted of a misdemeanor? (Applicants may answer ÒNOÓ with respect to a first conviction for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace.) 0 No   0 Yes

 

Have you been convicted of a felony? 0 No   0 Yes

 

If yes, please explain_________________________________________________________________________

 

VETERAN STATUS

Veteran of the U.S. Military Service? 0 No     0 Yes

 

If Yes, branch? _______________________________

 

Please describe any special skills or training acquired while in the service:

 

_________________________________________________________________________________________

 

FOREIGN LANGUAGE (If required of position)

Spanish  0 Speak  0 Read 0 Write                           French 0 Speak  0 Read 0 Write    

Vietnamese 0 Speak  0 Read 0 Write                      Other 0 Speak  0 Read 0 Write      

 

 

EMERGENCY INFORMATION

 

Name: ___________________________________________________________________________________

 

Relationship:______________________________________________________________________________

 

Phone #:_______________________________Alternate Phone#:____________________________________

 

 

 

 

EMPLOYMENT EXPERIENCE

 

Start with present or last job. Include Military Service Assignments and any verified work performed on a volunteer basis.  You may exclude names which indicate race, color, religion, sex or national origin.

 

Employer

Dates Employed:

From:            To:

Work Performed:

Address:

 

 

 

Hourly Rate:

Starting                    Final

 

 

Supervisor

      Phone:

 

Reason for Leaving                 

 

 

 

 

 

Employer

Dates Employed:

From:            To:

Work Performed:

Address:

 

 

 

Hourly Rate:

Starting                    Final

 

 

Supervisor

      Phone:

 

Reason for Leaving                 

 

 

 

 

 

Employer

Dates Employed:

From:            To:

Work Performed:

Address:

 

 

 

Hourly Rate:

Starting                    Final

 

 

Supervisor

      Phone:

 

Reason for Leaving                 

 

 

 

 

 

Employer

Dates Employed:

From:            To:

Work Performed:

Address:

 

 

 

Hourly Rate:

Starting                    Final

 

 

Supervisor

      Phone:

 

Reason for Leaving                 

 

 

 

 

IF YOU NEED ANY ADDITIONAL SPACE PLEASE CONTINUE ON A SEPARATE SHEET OF PAPER

SPECIAL SKILLS AND QUALIFICATIONS: Summarize special skills and qualifications acquired from employment or other experience:

 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

PROFESSIONAL REFERENCES

 

List three PROFESSIONAL REFERENCES who are NON RELATIVES.

 

Name:____________________________________________ Phone:_________________________________

 

Name:____________________________________________ Phone: _________________________________

 

Name:____________________________________________ Phone:__________________________________

 

 

 

 

 


It is my understanding that this employment application, or the granting of an oral interview, does not represent contract of employment or a promise of future compensation and benefits by the Agency. I understand and agree that if hired, my employment will be at will in nature and may be terminated with or without cause, or with or without notice, at any time, by either myself or my employer.  I also understand this written statement supersedes any and all oral representations made by agents or representatives of the agency.

 

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any application wishing to be considered for employment beyond this time period must file a new application.

 

AGREEMENT: I certify the information on this application is true, complete and correct. I authorize the agency to investigate my past employment, education and activities and I release from all liability all persons, companies and corporations supplying such information.  I understand that false answers, statements or significant omissions made by me on this form, shall be sufficient cause for denial of employment of discharge.

 

__________________________________________________________    _____________________________

Signature of Applicant                                                                                                Date