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Employees
Employment Application
Availability: check all that you could work
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day hours
Hours
:
Minutes
AM
PM
AM/PM
Evening Hours
Hours
:
Minutes
AM
PM
AM/PM
Nights (9PM-12MN)
Hours
:
Minutes
AM
PM
AM/PM
Overnights
Hours
:
Minutes
AM
PM
AM/PM
Live-in
Hours
:
Minutes
AM
PM
AM/PM
Date of Application
MM slash DD slash YYYY
Date Available for Employment:
MM slash DD slash YYYY
Position Applying For:
Type of Employment Desired:
Per Diem
Part Time
Full Time
Last Name
First Name
Middle Initial
Mailing Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Work Phone Number
Email
Language skills other than English (written/spoken)
Have you ever been employed here before?
Yes
No
If yes, when?
Are you legally eligible for employment in the US?
Yes
No
If not legal citizen: Do you have a green card?
Yes
No
Do you have a social security card?
Yes
No
Has your visa expired?
Yes
No
REFERRAL INFORMATION
How did you hear about us? (Please check)
Newspaper Ad
Internet
Current Employee
Other
Which newspaper?
Which site?
Other
We’d like to thank them
EMERGENCY CONTACT INFORMATION - Please Print Clearly
Name
First
Last
Relationship:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Sunrise Home Care Services an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status.
Employment History
Please begin with your most recent or current place of employment.
Place of Employment:
Start Date:
MM slash DD slash YYYY
Address:
End Date:
MM slash DD slash YYYY
Position:
Phone Number:
Supervisor:
Salary:
Reason for Leaving:
Final Salary:
Place of Employment:
Start Date:
MM slash DD slash YYYY
Address:
End Date:
MM slash DD slash YYYY
Position:
Phone Number:
Supervisor:
Salary:
Reason for Leaving:
Final Salary:
Place of Employment:
Start Date:
MM slash DD slash YYYY
Address:
Address:
MM slash DD slash YYYY
Position:
Phone Number:
Supervisor:
Salary:
Reason for Leaving:
Final Salary:
Education:
Name
First
Last
Location:
Course of Study:
Years Completed
Date Graduated:
MM slash DD slash YYYY
High School:
College:
Other:
Other:
Military Service:
Branch of Service:
Highest Rank Achieved:
Dates of Service:
MM slash DD slash YYYY
Currently in a Reserve Unit?
Yes
No
Special Schooling and/or Duties:
Licenses and Certifications:
ID Number:
Expiration Date:
MM slash DD slash YYYY
State:
Criminal History- By my signature below, I acknowledge/consent to a criminal check on my name.
Have you ever been convicted of violating any law? (Please omit minor traffic violations.)
Yes
No
if yes, please list conviction(s), date(s) and location(s). The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my cited previous employers or reference candidate for information regarding my character, employment history or work ethics.
Employee Candidate Signature:
Date:
MM slash DD slash YYYY
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