EMPLOYMENT APPLICATION

Are you looking for employment ?? Then you are at the right place. Just Fill our detailed employment application form below.

(* = Required )

First Name* Middle Name Family Name*



* 10-digit Home or Cell required
No dashes, special characters or spaces between numbers

Home Phone* Work Phone Cell Phone*
Email*
Street Address*
City* State* Zip Code*
County*



EMPLOYMENT DESIRED:

Position applying for*
Are you applying for?*


What days and hours are you available to work?*
Day of Week Start Time End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total Hours Available a Week


If applying for temporary work, during what period of time will you be available?
Start Finish


Are you available for work on the weekends?*  Yes No
Would you be able to work overtime if necessary?*  Yes No
If hired, on what date can you start?*
Salary desired?*
Currently employed?*  Yes No
May we contact your employer?*  Yes No
Can you legally work in the U.S.?*  Yes No

Proof of citizenship or immigration status will be required upon employment.


Who referred you to this company?*

EDUCATION, TRAINING and EXPERIENCE
Education
Name and Address
Years Completed
Graduated?
Degree/Diploma
High School  Yes No
College/University  Yes No
Vocational/Business  Yes No
Healthcare  Yes No



Many of our patients/clients do not speak English. Do you speak, write or understand and foreign languages?  Yes No
If yes, which language(s)?



Do you have other experience, training, qualifications or skills which you believe make you especially
suited for work at theis company? If so, please explain below.

Answer the following questions if you are applying for a professional position.
Are you licensed/certified for the job applied for?  Yes No

License Name Issue Date Number

Has your license/certificate ever been revoked or suspended?  Yes No
If yes, state reason(s), date of revocation or suspension and date of reinstatement.


FORMER / CURRENT EMPLOYERS

Name of Employer* Type of Business*
Address*
Employer's Telephone* Supervisor's name*
Your position and duties*
Date of Employment: From* To*
Weekly Pay: Starting* Ending*
Reason for leaving*


REFERENCES (* 3 Required)

Name
Address
Business
Years Acquainted


SERVICE RECORD

Branch of Service
Discharge date
Rank


Have you been convicted of a felony within the last five years?  Yes No
If YES, explain (This will not necessary exclude you from consideration.)


By initialling and entering my name below, I certify that all information provided in this application is complete, accurate, and true to the best of my knowledge.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company andy and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for not definite or determinable period and may be terminated at any time, with or without prior notice, ant the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company's designated representative.



Applicant's Signature* Date*



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