Application For Employment

Name *

First Name

Last Name

Home Phone *

(###)

###

####

Business Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever applied for employment with this Agency? *

Yes

No

Are you legally eligible for employment in the United States?

Yes

No

How did you learn of our organization?

Newspaper Ad

Agency employee

Other

Are you willing to work: *

Evenings?

Weekends?

Was your last name different from your present name during the above listed jobs? *

Yes

No

Are you currently employed? *

Yes

No

Do you have reliable transportation? *

Transportation is available through Ram In The Bush Home Care Services.

Yes

No

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency? *

Conviction will not necessarily disqualify an applicant for employment.

Yes

No

Do you certify that the facts contained in this application are true and complete to the best of your knowledge and understand that, if employed, falsified statement on this application SHALL BE GROUNDS FOR DISMISSAL? *

Yes, I do.

No, I do not.

Do you Authorize complete investigation of all statements contained herein and hereby give your full permission for the Agency to contact and fully discuss your background and history with all persons and entities listed above to give the Agency any and all information concerning your previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency? *

Yes, I do.

No, I do not.

Do you understand and agree that, if hired, your employment is for no definite period and may, regardless of the date of payment of your wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause? *

Yes, I do.

No, I do not.

Date *

MM

DD

YYYY