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Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alternative Telephone No.

Best Time To Call:*

Email*

Are You Applying For:*

Full Time (=80HRS/PP)
Part Time (<80HRS/PP)

Any Previous Name(s)? If yes, identify all other names including maiden name:

Positions applied for: Wage/Salary Expected:*

Shift Preference

Select All
Days
Evenings
Nights

How were you referred to this organization?*

Have you ever been employed by this organization?*

Yes
No

If Yes, when were you employed?

Relatives or friends employed by this organization?*

Yes
No

Name of Relative or Friend Employed

First

Department of Relative or Friend Employed

Are you a U.S. Citizen or an Alien Legally Authorized to work in the United States?*

Yes
No

Have you ever been convicted of, or plead guilty to, a crime (excluding misdemeanor traffic violations)?*

Yes
No

If you answered yes to the question above, please provide an explaination:

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state in the United States?*

Yes
No

If you answered yes, to the question above, please provide an explanation:

Name of High-School Attended:

Last Year Completed of High School:

Name of College Attended:

College Course of Study:

Did you graduate College?

Yes
No

Last Year Completed of College:

Other Business or Special Courses: (Including Special Military Training, Post Graduate or Nursing).

Area(s) of Specialization or Major Interest:

List Health Care, Business or Industrial Equipment Operated (optional):

Professional Licenses:

Currently Licensed
Currently Registered
Eligible for License
Eligible for Registration

License or Registration EVER suspended, revoked, or on probation?*

Yes
No

If you answered yes, to the question above, please provide an explanation:

Professional Certifications:*

Currently Certified
Eligible for Certification
No Certifications

Date

State of Certification:

Do you speak a language other than English?*

Yes
No

List other languages spoken and fluency level (speak/read/write at a fair/good/fluent level)

Did you serve in the U.S. Armed Forces?*

Yes
No

What Branch?

Have you ever volunteered your time and services?*

Yes
No

Where?

Briefly describe duties and skills acquired through military or volunteer service: (include dates)

Previous Employment

Provide information regarding previous employment beginning with most recent employer.

Job Title

Employer

Phone

Address

Street Address Address Line 2 City State ZIP Code

Duties

Reason for Leaving

From

To

Supervisor's Name

Job Title

Employer

Phone

Address

Street Address Address Line 2 City State ZIP Code

Duties

Reason for Leaving

From

To

Supervisor's Name

Job Title

Employer

Phone

Address

Street Address Address Line 2 City State ZIP Code

Duties

Reason for Leaving

From

To

Supervisor's Name

Job Title

Employer

Phone

Address

Street Address Address Line 2 City State ZIP Code

Duties

Reason for Leaving

From

To

Supervisor's Name

Please identify and explain any gaps in employment longer than three (3) months

References

List at least three (3) references who are not relatives or employers

Name and Relationship

Title

Company Name and Address

Telephone

Name and Relationship

Title

Company Name and Address

Telephone

Name and Relationship

Title

Company Name and Address

Telephone

CAPTCHA

Employment Application

Previous Employment

References

Oak Crest

DeKalb Area Retirement Center