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Employment Application

Applicant Information

Appliation Date*
Name*
Physical Address*
Mailing Address*
Date of Birth*
Marital Status:*
Employment Desired*
Check all that apply.
Date Available to Start*
Ending Date if Required
List the hours you are availble to work.
Desired Work*
Shifts Desired*
Are you a citizen of the United States?*
If No, can you furnish a Visa?*
Are you under 18 years of age?*
If Yes, can you furnish a work permit?*
Have you ever applied to this company?*

Education Information

Did you graduate?*
GED?
Did you graduate college?
Military Service
English?
Foreign Language?
Desires, Passions, etc.

Professional References

Full Name*
Full Name

Personal References

Full Name*
Full Name

Emergency Contact Information

Full Name
Address

Previous Employment

May we contact your previous supervisor for a reference?*

Previous Employment 2

May we contact your previous supervisor for a reference?

Previous Employment 3

May we contact your previous supervisor for a reference?

Additional Questions and Authorizations

Have you ever been convicted of a felony?*
Do you agree to a background criminal history check via the CBI?*
Do you agree to provide agency with any changes in criminal history, licensing or legal actions?*
Do you agree to a CAPS check from Adult Protective Services to ensure no threat to clients or agency?*
Do you agree to provide a copy of your valid driver’s license and to keep it current and valid?*
Do you agree to provide a copy of your valid car insurance and to keep it current and valid?*
Do you have a reliable vehicle which can get you around in the snow?*
Do you agree to provide a copy of another form of ID?*
Social Security Card/Passport/etc.
Do you agree to provide accurate information on the Pre-Employment Physical and Health History Questionnaire and to update the agency if any health information changes in this questionnaire which could inhibit you from completing required assignments?*
Do you agree to receive the required influenza “Flu” vaccine annually, BY November 1st and provide Agency with proof?*
Do you agree to company COVID policies and to be fully vaccinated as required?*
If required, do you agree to provide proof of your Licensing, Certifications, or CPR status?
Do you understand the confidentiality of information?*
Do you agree to not share the agencies information during employment and after termination?*
Do you agree to follow the agencies policies and procedures?*
Do you agree to inform the agency immediately of any changes to the above information?*
Do you have a smart phone and capable of using it with our software?*

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge and false or misleading information in my application or interview may result in my release.I understand the company is an Equal Opportunity Employer and does not discriminate.I understand that this application is valid for 60 days from the date signed below and may be kept on file for future referencing.If employed or during the interviewing process I agree to inform the agency immediately of any changes to the above information listed in this application.

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