Application Form

Step 1 of 10

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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.

Personal Information

Last Name

First Name

Middle Name

Date

Street Address

Home Phone

City, State, Zip Code

Business Phone

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?

Online Ad

Agency employee

Other

Are you willing to work

Evenings?

Weekends?

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

1. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

Starting Pay

Job Title and describe your work

Reason for leaving

2. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

Starting Pay

Job Title and describe your work

Reason for leaving

3. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

Starting Pay

Job Title and describe your work

Reason for leaving

4. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

Starting Pay

Job Title and describe your work

Reason for leaving

5. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

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

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Credentials/specialized skills & qualifications/equipment operated

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

Please read all statements below before signing this application

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.

This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.

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

Signature