Employment Application

We are an Equal Opportunity Employer. It is our policy to abide by all Federal, State, and Local laws concerning discrimination in employment. No questions in this application is intended to elicit information in violation of any such law nor will any information obtained in response to any questions be used in violation of any such law.

Application Date:

Last Name:*

First Name:*

Address: *

City: *

State: *

Zip Code: *

Telephone:*

Date Available for Work:*

Employment Type:*

Full Time

Part Time

Were you previously employed by this organization?

Yes

No

If Yes, What are the dates you worked:

Start Date:

End Date:

If Yes, what was your department/Position:

List any relatives or friends Working for this organization (include names and relationships):

LIST PRESENT AND FORMER EMPLOYERS BEGINNING WITH MOST RECENT

Work Experience 1

Start Date:

End Date:

Company Name and Address:

Telephone:

Position Held:

Describe your work:

Supervisor:

Last Wages:

Reason for Leaving:

Work Experience 2

Start Date:

End Date:

Company Name and Address:

Telephone:

Position Held:

Describe your work:

Supervisor:

Last Wages:

Reason for Leaving:

Work Experience 3

Start Date:

End Date:

Company Name and Address:

Telephone:

Position Held:

Describe your work:

Supervisor:

Last Wages:

Reason for Leaving:

Work Experience 4

Start Date:

End Date:

Company Name and Address:

Telephone:

Position Held:

Describe your work:

Supervisor:

Last Wages:

Reason for Leaving:

May we contact the above employers:

Yes

No

If “No”, indicate which one (s) you do not wish us to contact:

How did you learn of this position?

Ad

CareerLink posting

Referred by another person

Walk-in

Other

If referred by another person, please let us know who that person is:

Special Skills and Qualifications:

Education

Professional References (no family members or friends)

Miscellaneous Information

Can you verify your legal rights to work in the U.S. by providing a birth certificate, proof of U.S. Citizenship, or by some other means?

Yes

No

If you are under 18 can you furnish a work permit?

Yes

No

Are you able to perform the job (s) for which you are applying for?

Yes

No

APPLICANT’S CERTIFICATION

APPLICANT’S CERTIFICATION – Please read carefully before signing*

Employment at Will: If employed, I understand and agree that such employment may be terminated at any time, without prior notice, and that my employment will not be governed by any expressed or implied contract but is at-will.

I certify that to the best of my knowledge and belief, the answers given by me to the foregoing questions and the statements made by me in this application are correct and complete. I understand that misrepresentation or omission of facts in this application may result in my discharge.

I hereby give the Employer the right to investigate all references unless otherwise stated herein.

For Personal Care Attendant applicants: I understand that I will be dismissed from employment if I have been named as a perpetrator of a “founded” or “indicated” report of child abuse, or have been convicted of any crimes in violation of the Older Adult Protective Services Act, Act 28 of 1995, Act 169 of 1996, Act 13 of 1997, or equivalent crime in another state.

I understand that submission to a criminal conviction check is a condition of employment with the company. Failure to submit to such a check will result in ineligibility for hire or my employment being terminated.

I understand that this employer is a Drug-Free Workplace employer.

Applicant’s Signature:*

Date:*