Employment Application

Personal Information
Name: (First, M, Last)	*
Address:		Phone (Home):	*
		Cell Phone / Pager:
City,State, Zip:	,	Email:	*
Are you over the age of 18? Yes / No *
Are you a US Citizen? Yes / No *
If no, do you have the legal right and necessary documents to work in the US? (Identity and employment eligibility will be verified as required by law.) Yes / No

Employment Information
Position Desired:		Part Time Full Time	Shift Preference
Salary Requirement:		Date Available:
Do you possess a valid driver’s license?	Yes / No
Do you have your own transportation?	Yes / No
Have you applied here before?	Yes / No	If so, when?
How were you referred to us?		Please Tell Us:

Qualifications & Experience
Education		Did You Graduate?	If No, Please Explain
High School		Yes / No
College		Yes / No / N/A
Nursing School		Yes / No / N/A
Technical Training		Yes / No / N/A

Languages spoken in addition to English
Can you perform all of the job-related functions of the position(s) for which you are applying? Yes / No
If no, please explain:
Do you have current CPR certification? Yes / No		Expiration date:
Why do you want to work for this agency?

Past & Present Employment
Current Employer
Name		Phone
Supervisor		Position
Address		Start Date
		Salary
City, State, Zip	,	May we contact?	Yes / No
Past Employers
Name		Phone
Supervisor		Position
Address		Salary
		May we contact?	Yes / No
City, State, Zip	,	Start Date
Reason For Leaving		End Date

Name		Phone
Supervisor		Position
Address		Salary
		May we contact?	Yes / No
City, State, Zip	,	Start Date
Reason For Leaving		End Date

References
Name		Phone
Address		Relation
		Years Acquainted
City, State, Zip	,

Name		Phone
Address		Relation
		Years Acquainted
City, State, Zip	,

Name		Phone
Address		Relation
		Years Acquainted
City, State, Zip	,

Criminal Background Inquiry
Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime? Yes / No *
If yes, please explain: (You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.)


“I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.”

Signature:	*	Date:	*
	Please print your name in the box above. This will represent your signature on this electronic application.