All prospective employees will receive consideration without discrimination because of race, color,
creed, age, natural origin or handicap. All information provided herein will be kept confidential.
PERSONAL
Have you ever applied for employment with this Agency?
Are you legally eligible for employment in the United States?
How did you learn of our organization?
EDUCATION
Diploma College
Vo-Tech or Trade
High School
Other
EMPLOYMENT
List the last five years employment history, starting with the most recent employer.
_________________________
_________________________
_________________________
_________________________
Was your last name different from your present name during the above listed jobs?
Are you currently employed?
Do you have reliable transportation?
PROFESSIONAL REFERENCES
Persons who can furnish information about job performance.
_________________________
_________________________
GENERAL
er been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
Conviction will not necessarily disqualify an applicant from employment.
Are you capable of performing the job set forth in the job description?
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED
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 herby 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 of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.