Application for Employment

Required fields are marked with an asterisk*

Position applying for*

Employment status applying for Employment status applying for Full-Time Part-Time

Name*

Email Address*

Address*

Phone Number*

Additional Phone Number

Date available to start work

Expected pay

Are you legally qualified to work in the U.S.?* Are you legally qualified to work in the U.S.?* Yes No

Are you under the age 18?* Are you under the age 18?* Yes No

With or without reasonable accommodation, are you able to perform essential functions of the job for which you are applying?* With or without reasonable accommodation, are you able to perform essential functions of the job for which you are applying?* Yes No

If answer to the above question is no, briefly explain

Do you have reliable transportation?* Do you have reliable transportation?* Yes No

Have you been convicted of a crime involving mistreatment, neglect, abuse, homicide, sex offenses, domestic violence, theft, fraud, misappropriation of another person's property, conspiracy, weapons, or drugs?* Have you been convicted of a crime involving mistreatment, neglect, abuse, homicide, sex offenses, domestic violence, theft, fraud, misappropriation of another person's property, conspiracy, weapons, or drugs?* Yes No

If answer to the above question is yes, give dates and offenses

Can you work weekends? Can you work weekends? Yes No

Can you work overtime? Can you work overtime? Yes No

EDUCATION

Name of last high school

Did you graduate? Did you graduate? Yes No

Names of trade schools, locations, type of diplomas

Names of undergraduate schools, locations, type of diplomas

Names of graduate schools, locations, type of diplomas

Professional licenses and certifications. Type, state issued by, date issued, date expires.

List any experiences, skills or qualifications which you feel would make you a valuable employee

EMPLOYMENT HISTORY: EMPLOYER 1 of 3

May we contact this employer?* May we contact this employer?* Yes No

Name of employer*

Phone number of employer*

Address of employer*

Position held*

Dates employed*

Name of supervisor

Ending wage*

Briefly describe work performed*

Reason for leaving*

EMPLOYMENT HISTORY: EMPLOYER 2 of 3

May we contact this employer?* May we contact this employer?* Yes No

Name of employer*

Phone number of employer*

Address of employer*

Position held*

Dates employed*

Name of supervisor

Ending wage*

Briefly describe work performed*

Reason for leaving*

EMPLOYMENT HISTORY: EMPLOYER 3 of 3

May we contact this employer?* May we contact this employer?* Yes No

Name of employer*

Phone number of employer*

Address of employer*

Position held*

Dates employed*

Name of supervisor

Ending wage*

Briefly describe work performed*

Reason for leaving*

REFERENCES: REFERENCE 1 of 3 (Preferably work relationships, DO NOT list family)

Name of reference*

Address of reference*

Phone number of reference*

Relationship of reference to you*

REFERENCES: REFERENCE 2 of 3 (Preferably work relationships, DO NOT list family)

Name of reference*

Address of reference*

Phone number of reference*

Relationship of reference to you*

REFERENCES: REFERENCE 3 of 3 (Preferably work relationships, DO NOT list family)

Name of reference*

Address of reference*

Phone number of reference*

Relationship of reference to you*

SIGNATURE & FORM SUBMISSION

Enter your name here to sign this application and agree with the statement below

I CERTIFY THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE, AND UNDERSTAND THAT ANY MISLEADING OR FALSE INFORMATION OR WILLFUL OMISSION WILL BE SUFFICIENT CAUSE FOR IMMEDIATE DISMISSAL OR REFUSAL OF EMPLOYMENT. I UNDERSTAND THAT ALL INFORMATION IN THIS APPLICATION IS SUBJECT TO VERIFICATION AND THAT THE FACILITY MAY INVESTIGATE MY WORK AND PERSONAL INFORMATION AND VERIFY ALL DATA GIVEN ON THIS APPLICATION. I ALSO AUTHORIZE ALL INDIVIDUALS, SCHOOLS, BUSINESSES AND EMPLOYERS (PAST AND PRESENT), AND REFERENCES HEREIN, EXCEPT MY CURRENT EMPLOYER IF SO NOTED, TO PROVIDE ANY INFORMATION REQUESTED ABOUT ME, AND I RELEASE THEM FROM ALL LIABILITY FOR DAMAGE IN PROVIDING THIS INFORMATION. I FURTHER UNDERSTAND THAT EMPLOYMENT IS “AT-WILL” AND THAT NOTHING CONTAINED IN THIS EMPLOYMENT APPLICATION OR STATEMENTS MADE DURING THE INTERVIEW PROCESS IF AN INTERVIEW IS GRANTED, ARE INTENDED TO CREATE AN EMPLOYMENT CONTRACT BETWEEN THE FACILITY AND MYSELF FOR EITHER EMPLOYMENT OR FOR THE PROVIDING OF ANY BENEFIT.

AN EQUAL OPPORTUNITY EMPLOYER
ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, DISABILITY, VETERAN STATUS, OR ANY OTHER CHARACTERISTIC PROTECTED BY LAW. PLEASE DIRECT ANY REQUEST FOR REASONABLE ACCOMMODATIONS NEEDED DURING THE APPLICATION PROCESS TO AN ADMINISTRATOR.