First
Name:
Middle
Name:
Last Name
Email
Address:
Phone:
Home
Address:
How long
have you lived at this address?
Job
Applied for:
Date You
Can Start:
Salary
Desired:
Hours You
Would Prefer
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If
part-time, what hours work best for you and why?
What
shift(s) would work for you?
If you
have been at your current residence for less than three years, please list
the other addresses where you have lived over the past three years. Please
indicate when you moved into each address and when you moved out of each
address.
Are you
18 years or older?
Have you
been convicted of a felony?
If yes,
please explain:
Have you
worked for Handi-Care before? If yes, when?
If you
can do so now, please give three personal references. If you skip this
question now, this will be required during the interview process. Feel free
to e-mail your references to us later. Provide the name, address, phone,
and occupation of each. Do not list relatives or former employers as
personal references.
Write a
brief summary about your qualifications for the job applied for:
May we
contact your present employer at this time?
Not applicable. I am not currently employed .
Employment
History - We ask for information on the three most recent employers in your
employment history. Current or most recent employer:
Address
of employer:
Month and
year you started with this employer:
Month and
year you left this employer:
Reason
for leaving:
Job
Duties
Weekly
Salary
Reason
for Leaving:
Name of
Supervisor:
Phone
Number for Reference:
Next most
recent employer:
Address
of employer:
Month and
year you started with this employer:
Month and
year you left this employer:
Job
Duties:
Weekly
Salary:
Reason
for leaving:
Name of
Supervisor:
Phone
Number for Reference:
Name of
your next most recent employer:
Address
of Employer:
Month and
date you started with this employer:
Month and
date you left this employer:
Job
Duties:
Weekly
Salary:
Reason
for Leaving:
Name of
Supervisor:
Phone
Number for Reference:
Highest
education grade level attained (mark 12th if you comleted
highschool and went on to college or technical
school):
12th
11th
10th
9th
8th
7th
6th
5th
Name of
your grammer school and the city and state where
it was located:
Name of
high school and the city and state where it was located:
Name of
college / technical school and the city and state where it was located:
Last year
completed in college / technical school:
Not applicable
1
2
3
4
5
6
Additional
comments which you feel would be important in our consideration of your
application:
I have
read the AFFIDAVIT. I understand it. I consent to it. Initials:
AFFIDAVIT: I agree
to sign a consent for random drug testing and
criminal background check. I agree to be employed
on a ninety- (90) day calendar probationary period and understand that my
employment may be terminated at any time during this period at the
discretion of the company. I agree to submit to a physical examination
whenever requested by the company. I authorize without liability
investigation of all statements in this application. I expressly waive all
provisions of law prohibiting any physician, person, hospital or other
institution that has or may hereafter attend or furnish me with treatment
from disclosing to the Company any knowledge or information hereby
acquired. I authorize all schools which I attended and all previous employers
to furnish to the Company my record, reason for leaving and all information
they may have concerning me and I hereby release them and the Company from
all liability for any damages whatsoever arising therein. I authorize my
neighbors, friends or others with whom I am acquainted or
who are acquainted with me to furnish the Company with information used in
connections with the evaluation of my qualifications as a prospective
employee . I also authorize the making of an
investigative consumer report whereby information may be obtained
concerning my character, general reputation, personal characteristics and
mode of living, whichever may be applicable I understand I have the right
to make a written request within a reasonable period of time for a complete
and accurate disclosure of information concerning the nature of scope of
the investigation. I understand that in the event of my employment
by the Company, it shall be sufficient cause for dismissal if any of the
information I have given in this application is false or if I have failed
to give any information herein requested. In the event of my employment by
the company, I agree to abide by all present and subsequently issued rules
of the Company. I understand and agree that, if hired, my employment is for
no definite period and may, regardless if the date of payment of my wages
and salary, be terminated at any time without
prior notice.
