a. |
Mention the highest high school grade completed 1,2,3,4,5,6,7,8,9,10,11,12 and Year Completed |
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b. |
If you have not completed high school, do you have equivalency diploma? Yes/No & Date Received. |
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c. |
Select Number of years of post high school education
1
2
3
4
5
6
7 |
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| EXPERIENCE |
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May we contact your present supervisor? |
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Yes |
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No |
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A. |
Job Title |
Duties |
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Employer |
Phone |
Type of business |
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Address |
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Immediate supervisor |
Salary(start) |
(finish) |
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Dates Start (mo/yr) |
to (mo/yr) |
Reason for leaving |
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Full-time |
Part-time |
Hours/week |
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B. |
Job Title |
Duties |
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Employer |
Phone |
Type of business |
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Address |
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Immediate supervisor |
Salary(start) |
(finish) |
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Dates Start (mo/yr) |
to (mo/yr) |
Reason for leaving |
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Full-time |
Part-time |
Hours/week |
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C. |
Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, special achievements or specialized skills.
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| REFERENCES |
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List names, addresses and relationships of three persons not related to you who know your qualifications: |
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| MISCELLANEOUS |
a. |
Check which shift you will accept: |
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b. |
Check, which job status you would accept: |
Full Time
Part-time |
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Specify |
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c. |
For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States? |
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Yes |
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No |
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Under the Immigration Reform and Control Act of 1986, your will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be employed. |
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d. |
Are you willing to provide your own transportation if necessary for your employment? |
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Yes |
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No |
e. |
Have you ever been convicted* for any violation(s) of law? |
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Yes |
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No |
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Description of offense |
Statute or ordinance (if known) |
Date of Charge |
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Date of Conviction |
Country, City and State of Conviction |
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*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching or Aggravated Malicious Wounding, If you were age fourteen (14) to eighteen (18) when charged. |
| When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.) |
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| Certification |
| I herebv certify that all entries are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the Angel Senior Home Care, LLC. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further authorize the Angel Senior Home Care, LLC. To rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need to- know basis for good cause shown as determined by the agency head or designee. |
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Date |
Applicant Signature |
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