APPLICANT INFORMATION
Last Name
First
MI
Street Address
City
State
ZIP
Phone
E-mail Address
Date Available
Social Security No.
Desired Salary
Position Applied for
Full Time
Part Time
Pool
Nights
Days
Evenings
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
If Yes, explain:
How were you referred to Craig HomeCare?
EDUCATION
High School
Address
Did you graduate?
Yes
No
Degree
College
Address
Did you graduate?
Yes
No
Degree
Other
Address
Did you graduate?
Yes
No
Degree
REFERENCES
Please list three professional references
Full Name
Relationship
Company
Phone
Full Name
Relationship
Company
Phone
Full Name
Relationship
Company
Phone
MILITARY SERVICE
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain:
PREVIOUS EMPLOYMENT (START WITH MOST RECENT)
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
If No, please explain:
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
If No, please explain:
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
If No, please explain:
OTHER SKILLS/TRAINING
DISCLAIMER AND SIGNATURE
Craig HomeCare is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Craig HomeCare to verify their accuracy and to obtain reference information on my work performance. I hereby release Craig HomeCare from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. This application will remain active for 45 days from the date of application.
I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.
I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Craig HomeCare. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Craig HomeCare may terminate my employment at any time with or without notice or cause.
Signature
Date
(type name if in agreement with above statements)
By clicking on the submit button below, you certify that you have read the application form terms and agree to its content. You further certify that the information submitted in this application is true and correct to the best of your knowledge.
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