APPLICATION FOR EMPLOYMENT	Date
Our company is an equal opportunity employer, and will consider all applicants regardless of their race, age, color, religion, national origin, veteran status, or any disability as provided by the Americans With Disabilities Act. This application will be given every consideration, but its receipt in no way implies that the applicant will be employed.
PERSONAL
Name (Print)

SS #
Email
Permanent Address	Phone #
Cell #
Birthdate	License/ID #	Expiration Date	State
Emergency Contact (Print)
Emergency Contact Address	Phone #
Cell #
Position(s) Interested In (List)	Part-Time	Temporary
Relief	Full-Time
EDUCATION	TRAINING
Level of Education (Circle Highest Level)	Masters	BA/BS	AA	Diploma	GED	Training	Yes	No	Expiration Date
# Years Completed	CPR
High School Name

First Aid
HIV/AIDS/Infection Control
High School Location

HIPAA
Medication Admin
College/University Name	Medication Validation
Direct Care Core Competency
Zero Tolerance
College/University Location	SLC Pre-Service (18 hours)
SLC - Soical Security Work Incentives
Continuing Education Classes/Other Training (List)	Requirements for All Waiver Providers
CNA
HHA
EXPERIENCE
Current Work History	List your current employment.
Current Company/Location	Job Duties	Supervisor/Phone	Start Pay	End Pay	From-To (mm/yy)	Reason Left

Past Work History	List your work experience covering the past five (5) years, beginning with most recent. Give month and year.
Company Name/Location

Job Duties	Supervisor/Phone	Start Pay	End Pay	From-To (mm/yy)	Reason Left

REFERENCES List five (5) references, including three (3) work and two (2) non-family, personal references.
Reference Full Name	Company Name	Relationship	Phone Number	Work	Personal	Admin Checked
GENERAL INFORMATION	Yes	No
1. Are you a United States citizen?	*
2. Do you have a legal status to be employed in the United States?	*
3. Have you ever been convicted of any crime including driving under the influence of drugs or alcohol?	*
4. Have you ever had a misdemeanor or a felony for any reason?	*
Explain any answers with *. For 3 and 4, state the offense, date, location, and disposition.

Would you be willing and able to perform all tasks required by the job you are applying for?

Have you filed any type of fraudulent claim against any of your past of present employers?

How many days of work or school have you missed in the last two years?

Would you be willing and able to report to work on time every day on a consistent basis, including irregular work schedules?

Please note that you are applying for a position of trust and responsibility. A background investigation will be performed on you. You will be required to sign an oath that you have not committed any felonies, complete fingerprinting, and undergo an abuse/neglect investigation prior to consideration for employment. Completion of the background screening and receipt of the results in no way implies that the applicant will be employed.

I understand the investigation procedures and state that all information on this application is true and valid, without any omissions. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application or during any interviews may be grounds for immediate discharge.

I hereby authorize the company to contact any company or individual it deems appropriate to investigate my employment history, character, and qualifications and I give full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals or groups for defamation, invasion of privacy, or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of employment and refusal to take such tests when asked will be grounds for immediate dismissal. I further understand that nobody in the company is authorized to enter into any written or verbal employments contracts with me for any definite period of time without the express written consent of the Program Administrator of the company. I also understand that my employment is "at-will" and may be terminated by myself or the company at any time for any reason at all, with or without prior notice.
Signature	Date
***OFFICE USE ONLY***
Background Screening Results Received	Comments
References Checked
Education/Experience Checked
Hire Date
Termination Date/Reason for Termination