Career

First Name

Last Name

Email Address

Primary Phone

Secondary Phone

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Emergency Contact

First Name

Last Name

Relationship

Phone

Employment Status and Availability

Are you legally eligible for employment in the United States?

Yes NO

Have you ever applied for employment with this Agency?

Yes NO

How did you learn of our organization?

Online Ad Agency Employee Internet Search Other

How many hours a week are you available for work?

Are you willing to work evenings?

Yes No

Are you willing to work weekends?

Yes No

Education Background

College Name

Location

Year of Graduation

Degree Earned

Vo-Tech or Trade School Name

Location

Year of Graduation

Degree Earned

High School Name Or GED

Location

Year of Graduation

Degree Earned

Employment History

(List at least Five years of employment history, starting with your most recent employer.)

Company Name

Company Phone

Company Address

Date of Employment (Start)

Date of Employment (End)

Still employed?

Yes No

Reason for leaving

Job Description

Have you changed your name?

Yes No

Please state your new name

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance (Must be professional references)

Name

Position

Phone

Name

Position

Phone

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes No

Are you capable of performing the job set forth in the job description?

Yes No

APPLICATION FOR EMPLOYMENT

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.

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 hereby 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 not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether applications are being accepted at that time.

Date

Name

Job Opportunities

Career

Career On gentle Springs Care

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