Employment Application

Join our Team

Make a difference. Build a compassionate career changing lives.

Full Name

Address

Phone

Email

Date of Birth

Social Security No

Desired Hours

Position Applied for

Are you a citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company?

Yes No

If yes, when?

Have you ever been convicted of a felony?

Yes No

High School

Address

From

To

Did you graduate?

Yes No

Diploma

College

Address

From

To

Did you graduate?

Yes No

Degree

Other

Address

From

To

Did you graduate?

Yes No

Degree

Please list three professional references.

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

Do you have a car?

Yes No

Driver’s License #

Expiration

If you don’t have a car how would you get to work?

How many hours can you work weekly?

Are you available to work nights?

Yes No

Are you legally authorized to work in this country?

Yes No

Would you consider live-in?

Yes No

Employment Desired

Full Time Part Time

Are you available to work weekends?

Yes No

Available to Start Date

Are there any times you are not available to work?

Certification and Release Section

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that the withholding, misrepresentation or falsification of information shall be grounds to refuse employment, or, if employed, shall be grounds for dismissal.