Employment Application Last Name First Name Middle Date Cell Phone Home Phone Street Address Email City State Zipcode S.S.# Birth Date Emergency Contact (Person not living with you) Have you ever applied for employment with this Agency? YesNoHow many hours a week are you available to work? Are you legally eligible for employment in the United States? YesNoHow did you learn of our Agency? Newspaper AdAgency EmployeeOtherAre you willing to work: EveningsWeekendsPosition Applying For: Therapist (Specify): Diploma College: School, Location, Course of Study, Years Attended, Degree/Study Vo-Tech or Trade: School, Location, Course of Study, Years Attended, Degree/Study High School: School, Location, Course of Study, Years Attended, Degree/Study Other Education: School, Location, Course of Study, Years Attended, Degree/Study 1. Employment History: List the last five years of employment history, starting with the most recent employer. Job title and describe the work you did: Company Address: Phone Number Email Dates of Employment (Form: - To:) Rate of Pay 2. Employment History: Job title and describe the work you did: Company Address: Phone Number Email Dates of Employment (Form: - To:) Rate of Pay 3. Employment History: Job title and describe the work you did: Company Address: Phone Number Email Dates of Employment (Form: - To:) Rate of Pay 4. Employment History: Job title and describe the work you did: Company Address: Phone Number Email Dates of Employment (Form: - To:) Rate of Pay 5. Employment History: Job title and describe the work you did: Company Address: Phone Number Email Dates of Employment (Form: - To:) Rate of Pay Was your last name different from your present name during the above listed jobs? YesNoIf Yes, what was your name? Are you currently employed? YesNoDo you have reliable transportation? YesNo1. Professional Reference Name Professional Reference Address Professional Reference Phone Professional Reference Email 2. Professional Reference Name Professional Reference Address Professional Reference Phone Professional Reference Email 3. Professional Reference Name Professional Reference Address Professional Reference Phone Professional Reference Email Available Days and Times MondayTuesdayWednesdayThursdayFridaySaturdaySundayPlease select all that applyFrom For each day, list your START time.To For each day, list your END time.County you can work in ElkoEurekaLanderWhite PineOtherPlease check the counties you can work in.Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and Community Support Agency? YesNoConviction will not necessarily disqualify an applicant from employment. If Yes, describe in full: Are you capable of performing the job set forth in the job description? YesNoIf you answered No, which job requirement can you not meet? CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED List all states in which you are licensed. Be sure to give registration and expiration date. Summarize special job related skills and qualifications acquired from employment or other experience. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I Authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my results from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time. Full NameDate PhoneSubmit
