PERSONAL

Last name

First name

SS/DL#

Present address

Home phone

Modile number

Email again

Permanent Address, if different from present address

If hired can you provide proof that you are legally able to work in the United States?

How were you reffered to us?

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Employment Agency
Walk-in
Other

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Note: An affirmative answer will not necessarily result in disqualification for employment

If yes, please state nature of offence(s), date(s), city, state

List any relatives or friends employed by the Company

Relationships

EMPLOYMENT

Position desired

Salary desired

What days and hours are you available to work?

Are you available for overtime?

Are you over 18 years old?

When you are available to begin work?

If under 18, can you provide a work permit?

Are you available to perform the essential functions of the job for which you are applying?

(Note: We comply with the Americans with Diabilities Act and consider reasonable accomodation measures that may be neccesary for eligible applicants to perform essential functions)

SKILLS

Many of our [customers/clients/patients] do not speak English. Do you speak, write or understand any foreign language?

If yes which language(s) and with what proficiency

Are you able to operate a personal computer?

Types of software

List other office machines you can operate

Specific skills or training: What knowledge, special skills and/or individual capabilities do you have which especially prepare you for the position applied for?

EDUCATION

High School or Trade School

Name & Location of School

# of years to completed

Graduated

Degree(s) or Diplomas(s)

Major Field(s) of Study

Business or Tech. School

Name & Location of Business or Tech. School

# of years to completed

Graduated

Degree(s) or Diplomas(s)

Major Field(s) of Study

Jr. College and/or University

Name & Location of Jr. College and/or University

# of years to completed

Graduated

Degree(s) or Diplomas(s)

Major Field(s) of Study

Other Training (Explain)

Name & Location

# of years to completed

Graduated

Degree(s) or Diplomas(s)

Major Field(s) of Study

EMPLOYMENT HISTORY

Experience: Please account for all employment within the last seven (7) years, beginning with your current or more recent employer. In addition, please indicate any other experience which you believe is relevant to the position for which you are applying (e.g., volunteer experience. military service, experience gained over seven (7) years prior, etc.) Fill an additional sheet.

Answer all of the following questions if you are applying for a professional, licensed or certified position

Are you licensed/certified for the job you are applying for?

Name of license/certification

Issuing state

License certification number

Has your license/certification ever been revoked or suspended?

If yes, explain

Positions Held

Company Name

Street Address

City, State, Zip Code

Telephone

Supervisor

Is this your current employer?

May we contact this employer?

Dates Employed

From //

To //

Job Title

Starting Salary

Ending Salary

Hours Worked

From

Specific Job Duties

Reason for leaving

What is the most important skill demonstrated on the job?

Positions Held (cont.)

Company Name

Street Address

City, State, Zip Code

Telephone

Supervisor

Is this your current employer?

May we contact this employer?

Dates Employed

From //

To //

Job Title

Starting Salary

Ending Salary

Hours Worked

From

Specific Job Duties

Reason for leaving

What is the most important skill demonstrated on the job?

Company Name

Street Address

City, State, Zip Code

Telephone

Supervisor

Is this your current employer?

May we contact this employer?

Dates Employed

From //

To //

Job Title

Starting Salary

Ending Salary

Hours Worked

From

Specific Job Duties

Reason for leaving

What is the most important skill demonstrated on the job?

Additional sheet

PERIODS OF UNEMPLOYMENT

From //

To //

Reason for Unemployment:

From //

To //

Reason for Unemployment:

From //

To //

Reason for Unemployment:

MILITARY SERVICE

Have you obtained and special skills or abilities as the result of service in the military?

If yes, please describe

PERSONAL REFERENCES

Please list at least two (2) persons NOT related to you who have known you for at least five (5) years.

Name

Address

Phone No.

Name

Address

Phone No.

APPLICANT'S STATEMENT

(Initial each numbered item as read)

The information that I have provided on this application is accurate to the best of my knowledge and may be verified by the Company or its agents.

I authorize all the schools, persons and organizations named in this application to provide any relevant information in their possession or knowledge to the agents of the Company, for use in deciding whether or not to offer me employment and specifically waive any required written notification. I hereby release the Company, my former employers and all other persons from any and all claims, demands, or liabilities arising out of or in any way related to such inquiry or disclosure.

I understand that the Company is committed to maintaining a drug and alcohol free work place. Accordingly, I may be subject to a pre-employment blood test, urinalysis or other drug/alcohol screening. I further understand that if employed, I may be subject to such a drug and alcohol screening if the Company has reasonable suspicion to believe that I am under the influence of a drug or alcohol. My consent to submit to such a test is required as a condition of employment and my refusal to consent shall result in a refusal to hire or, if already employed, termination.

I authorize the Company to obtain consumer reports from consumer reporting agencies for use in deciding whether or not to offer me employment. I understand that such reports may include information concerning my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I understand that if I am denied employment based upon information obtained in any credit report, I will be provided with the name, address, and telephone number of the consumer reporting agency, a copy of the report, and an explanation of my rights concerning it.

I understand and agree that any misrepresentation or omission of facts in this application will be justification for refusal or termination of employment, regardless of the time elapsed before discovery.

I understand and agree that the employment for which I am making application is, and is intern to be, at-will and such employment may be terminated at any time with or without cause, without prior notice, by either myself or the Company. There will be no agreement, express or implied between the Company and me for any specific period of employment, nor for continuing or Ion tem1 employment, unless made in writing, signed by an authorized representative of the Company.

I have complete the entire to the best of my ability and have carefully read the foregoing seven (7) statements.

Visual verification