Careers Form

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.

Last Name *

First Name *

Middle *

Birth Date *

Street Address *

Home Phone *

City *

State *

Zip Code *

Business Phone *

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Newspaper Ad

Agency Employee

Other

Are you willing to work

Evenings

Weekends

Position Applying For

Position Details

Therapist (Specify)

Other

School Name

Location of School

Course of Degree / Study

Years of Diploma

Vo-Tech or Trade

School Name

Location of School

Course of Degree / Study

Years of Diploma

School Name

Location of School

Course of Degree / Study

Years of Diploma

School Name

Location of School

Course of Degree / Study

Years of Diploma

List the last five years employment history, starting with the most recent employer.

(1) Company Name

Telephone

Address

Dates of Employment

City

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for Leaving

(2) Company Name

Telephone

Address

Dates of Employment

City

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for Leaving

(3) Company Name

Telephone

Address

Dates of Employment

City

State

Zip Code

Starting Pay

Job Title and Describe your work

Reason for Leaving

Was your last name different from your present name during the above listed jobs?

Yes

What was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Professional References

Persons who can furnish information about job performance

Address

Fax

Address

Fax

Address

Fax

Have you ever 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.

Yes

Describe in full

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

Yes

Which job requirement can you not meet?

CREDENTIAL/SPECIALIZED SKILLS & QUALIFICATION/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.

Date *

Applicant Name *

APPLICANT REFERENCE CHECK (1)

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by the applicant

Applicant Name

Date Of Application

Previous Employer

Contact Person

Applicant Name

Date

To be completed by previous employer

Dates of Employment

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason For Leaving

Rate Of Pay (Weekly/Biweekly/Salary)

Additional Comments (Training or Skills)

Reference check performed by

APPLICANT REFERENCE CHECK (2)

To Whom It May Concern:

To be filled out by the applicant

Applicant Name

Date Of Application

Previous Employer

Contact Person

Applicant Name

Date

To be completed by previous employer

Date of Employment

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason For Leaving

Rate Of Pay (Weekly/Biweekly/Salary)

Additional Comments (Training or Skills)

Reference check performed by