First and Last Name:

Email:

Mobile Number:

Home Number:

Best Number to Contact:

Street Address (including apt number):

City:

State:

Zip:

How Did You Hear About Us:

I am available to work:

Full-Time (more than 35 hours per week) Part-Time (less than 34 hours per week)

I am interested in the following type of work
(Please check all that apply):

First Shift      Second Shift      Third Shift

Monday     Tuesday     Wednesday    Thursday     Friday     Saturday     Sunday    

Requested Pay Rate (can provide a range):

Employment History or Volunteer Organization
(starting with most recent position)

Dates of employment/Volunteer Service:

Position:

Type of employment/Volunteer Service
(p/t, f/t, live-in, live-out, child care, elder care):

Description of duties:

Reason for leaving:

Employer 2

Dates of Employment/Volunteer Service:

Position:

Type of employment/Volunteer Service:

Description of duties:

Reason for leaving:

Employer 3

Dates of Employment/Volunteer Service:

Position:

Type of Employment/Volunteer Service:

Description of duties:

Reason for leaving:

Give a brief description of any additional experience related to this field:

Education Summary

List any applicable certifications or licenses:

Are you willing to take additional certification courses?

Yes No

Select your highest level of education:

High School College Other

If you are a college graduate list your degree:

Please list any post graduate studies:

Provide any additional skills or qualifications such as tutoring, exercise instruction, pet training, bi-lingual ability, etc.

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

**Please print and retain a copy of this preliminary application for your records.**