Careers Form

* = Required Information

Date of Application

Name:

Last *

First *

Middle

Address:

Street *

Apartment

City

State

ZIP

Alternate Address:

Street

City

State

ZIP

Contact Information:

Home Telephone *

Mobile Telephone

Email *

How did you learn about our company?

POSITION SOUGHT

Available Start Date

Desired Pay Range: (Hourly or Salary)

Are you currently employed?

Education

High School

Name and Location

Graduate?

Degree?

Major / Subjects of Study

College or University

Name and Location

Graduate?

Degree?

Major / Subjects of Study

Specialized Training, Trade School, etc.

Name and Location

Graduate?

Degree?

Major / Subjects of Study

Other Education

Name and Location

Graduate?

Degree?

Major / Subjects of Study

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

Yes

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Previous Experience

Please list beginning from most recent

Dates Employed

Company Name

Location

Role / Title

Job notes, tasks performed and reason for leaving:

Dates Employed

Company Name

Location

Role / Title

Job notes, tasks performed and reason for leaving:

Dates Employed

Company Name

Location

Role / Title

Job notes, tasks performed and reason for leaving:

Dates Employed

Company Name

Location

Role / Title

Job notes, tasks performed and reason for leaving:

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.

Employee Emergency Contact Information

*In case of emergency, please contact:

Name

Phone

Relationship

Address

Professional References

Persons who can furnish information about job performance

1. Name

Telephone

Fax

Address

2. Name

Telephone

Fax

Address

3. Name

Telephone

Fax

Address

General Information

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. If yes, describe in full:

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.

Date

Applicant Name

Interview Review

Applicant Name

Date

Review:

Personality:

friendly

average

quiet

Verbal skills:

excellent

average

poor

Communicates:

clear

somewhat clear

not very clear

Flexibility:

very flexible

somewhat

not flexible

Skill level:

higher skilled

moderately skilled

lower skilled

Appearance:

professional

semi-professional

not professional

Good Candidate for employment:

Yes

Overall Interview:

Interviewer

Date