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Application For Employment
Contact Information
First Name:
Date of Application:
Last Name:
Email Address:
Street Address:
City:
State:
Zip:
Primary Phone:
Secondary Phone:
If you are under 18 and it is required, can you furnish a work permit:
Yes
No
Are you a U.S. citizen or legally authorized to work in the United States:
Yes
No
Position(s) applied for:
Full-Time
Part-Time
For which schedules are you available?
Weekdays
Weekends
Evenings
Nights
Overtime
If part time specify days/hours available
Desired Wage:
Are you able to meet the attendance requirements of the position:
Yes
No
Are you able to preform the essential functions of the position for which you are applying?
Yes
No
If no, please explain :
Have you ever been employed here before
Yes
No
If yes, give dates:
From
To
Do you have any relatives or friends who work for the Facility
Yes
No
Are you registered with the Family Care Safety Registry?
Yes
No
If the job requires, do you have the appropriate valid driver's license?
Yes
No
Chauffeur's License?
Yes
No
Education
High School Details
Name
City/State
Degree
Diploma
GED
Additional School Details
School Name
City/State
Course of Study
Years Completed
Degree
If your school records are in a different name than above, please enter that name here:
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying
Employment History
Provide the following information of your past and current employers, starting with the most recent. Explain any gaps in employment in the comments section below.
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Immediate Supervisor and Title:
Reason For Leaving:
May we contact for reference:
Yes
No
Dates Employed
From:
To:
Hourly Rate/Salary Starting
$
Per
Hourly Rate/Salary Final
$
Per
Summarize the type of work performed and job responsibilities
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Immediate Supervisor and Title:
Reason For Leaving:
May we contact for reference:
Yes
No
Dates Employed
From:
To:
Hourly Rate/Salary Starting
$
Per
Hourly Rate/Salary Final
$
Per
Summarize the type of work performed and job responsibilities
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Immediate Supervisor and Title:
Reason For Leaving:
May we contact for reference:
Yes
No
Dates Employed
From:
To:
Hourly Rate/Salary Starting
$
Per
Hourly Rate/Salary Final
$
Per
Summarize the type of work performed and job responsibilities
Employer:
Telephone:
Address:
Starting Job Title/Final Job Title:
Immediate Supervisor and Title:
Reason For Leaving:
May we contact for reference:
Yes
No
Dates Employed
From:
To:
Hourly Rate/Salary Starting
$
Per
Hourly Rate/Salary Final
$
Per
Summarize the type of work performed and job responsibilities
Comments including explanation of any gaps in employment
References
List name and telephone number of three business/work references who are not related to you
Name
Telephone
No. Of Years Known
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