APPLICATION FOR EMPLOYMENT

ANSWER ALL OF THE QUESTIONS CAREFULLY AND COMPLETELY

PERSONAL


CURRENT ADDRESS


(If less than 5 years, please complete previous address)


PERMANENT ADDRESS

 (If different from above)


Yes No
Yes No
Yes No
(Required for verifying education, employment records and references)

Yes No
Full Time Part Time
1st 2nd 3rd
Yes No
Yes No
Yes No
Yes No

List relatives working with our organization:

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Other

CRIMINAL HISTORY

Your answers to these questions will be checked against local, state, and federal records. Failure to answer these questions accurately could be sufficient grounds for dismissal.

Yes No

Yes No


Yes No


Yes No

Yes No


Yes No
Yes No
Yes No

RECORD OF EDUCATION

Type Name and Location of School No. of Years Attended Degree Awarded Major Field
High School
College
Graduate
Trade, Business, Correspondence
Yes No

MILITARY SERVICE RECORD

Yes No

REFERENCES (Please do not list relatives)

Please list two references other than relatives or previous employers.


EMPLOYMENT HISTORY FOR THE PREVIOUS FIVE (5) YEARS AND BEYOND

List all present and past employment, beginning with your most recent position. You may attach a resume to this application, but it is essential that all of the following questions be answered. Please fill in all the blanks.
Employment dates:
Yes No
Pay rate:
Yes No


Employment dates:
Pay rate:
Yes No


Employment dates:
Pay rate:
Yes No


Employment dates:
Pay rate:
Yes No


Yes No

Yes No
Yes No
Yes No

APPLICANT'S ACKNOWLEDGMENT

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application or accompanying resume, letter of reference or other document will disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application or accompanying resume, letter of reference or other document will be cause for my dismissal at any time without prior notice. I hereby authorize investigation of all statements contained in this application. I agree to immediately notify the Company, during my period of employment, if hired, of any potential, pending or future criminal convictions, guilty pleas or no contest (nolo contendere) pleas or similar issues. If driving is a condition of my employment, I agree to immediately notify the Company if my driver.s license is suspended or revoked. I understand that if employed it is not for a definite period of time and that either the undersigned or the Company may end the employment relationship at any time, without specified notice or reason.
I acknowledge that this application will remain active for 60 days from this date. If I have not heard from the Company at the conclusion of this 60 day period, if I still wish to be considered for employment by the Company, it is my responsibility to complete a new application. If hired, I understand that this application becomes part of my official employment record.
Signature:
 

EQUAL EMPLOYMENT OPPORTUNITY POLICY

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age, marital status, disability or other classification protected by law. We assure you that your opportunity for employment with this Company depends solely on your qualifications.
Thank you for completing this application form and for your interest in our business.

APPLICATION FOR EMPLOYMENT

PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING

APPLICATION FORM WAIVER/RELEASE

At-will. I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment for a definite term, or to confer any right to remain an employee of the Company, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and the Company may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
 
 
Initials
Application Disclosure and Release. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is grounds for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others with relevant information (excluding any medical information except post-offer) that may be useful to the Company in making a hiring decision and hereby release the Company and such persons and organizations from any liability as a result of such contact. If employed, I also grant permission for the Company to release information concerning my employment to prospective employers and, I release the Company from any legal liability in releasing any information.
 
 
Initials
Drug and Medical Testing and Consent. I also understand that (1) the Company has a drug and alcohol policy that allows for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of any required testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.
 
 
Initials
Post Offer Medical Information and Release. I authorize the Company to obtain (post offer) a report containing medical information about me from a consumer reporting agency to be used for employment purposes. I understand that if I am given a conditional offer of employment, I may be required to accurately and truthfully complete a post offer medical questionnaire and/or undergo a physical examination, including a drug screening exam and x-rays, and I consent to the release to the Company of any and all medical information, as may be requested or required by the Company in judging my capability to do the work for which I am applying. I understand that if required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential and in a separate file.
 
 
Initials
Probationary Period. I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment with the Company is terminable at will for any reason by either party.
 
 
Initials
Zero Tolerance Abuse Policy. This organization has adopted a "Zero Tolerance" policy to ensure that all allegations of mistreatment, neglect or abuse as well as injuries of unknown origin are reported immediately to Program Director, Administrator and/or other officials in accordance with the law. Zero Tolerance implies that termination from employment will occur and criminal prosecution will possibly be sought against perpetrators of proven cases, including staff who fail to immediately report such an incident.
 
 
Initials
Signature of Applicant: