Step 1 of 10
10%
All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
Last Name First Name Middle Name Date MM slash DD slash YYYY Street Address Home PhoneCity, State, Zip Code Business PhoneEmergency contact (person not living with you)
Yes No
How many hours a week are you available for work?
Online Ad Agency employee Other
Evenings? Weekends?
Position applying for
School Name Location of School Course of Study Degree/Dip
List the last five years employment history, starting with the most recent employer.1. Company Name TelephoneAddress City, State, Zip CodeDates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Starting Pay Job Title and describe your work Reason for leaving2. Company Name TelephoneAddress City, State, Zip CodeDates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Starting Pay Job Title and describe your work Reason for leaving3. Company Name TelephoneAddress City, State, Zip CodeDates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Starting Pay Job Title and describe your work Reason for leaving4. Company Name TelephoneAddress City, State, Zip CodeDates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Starting Pay Job Title and describe your work Reason for leaving5. Company Name TelephoneAddress City, State, Zip CodeDates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Starting Pay Job Title and describe your work Reason for leaving
If yes, what was your name?
Persons who can furnish information about job performance1. Name TelephoneAddress 2. Name TelephoneAddress 3. Name TelephoneAddress
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full
If you answered No, which job requirement can you not meet?
List all states in which licensed giving registration and expiration date. Summarize special jobrelated skills and qualification acquired from employment or other experience.
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL
I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.
This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.Date MM slash DD slash YYYY Signature
To Whom It May Concern:
The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
To be filled out by applicant:Applicant Name Date of Application: MM slash DD slash YYYY Previous Employer Contact Person Address PhoneI hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given. Applicant’s SignatureDate MM slash DD slash YYYY To be completed by previous employer: Date of employment:From MM slash DD slash YYYY To MM slash DD slash YYYY Position Held
ResponsibilitiesReason for LeavingRate of Pay: (weekly/biweekly/salary) Additional comments (training/skills) Reference check performed by
Employee Name Current Address Home PhoneCell Phone*In case of emergency, please contact: Name PhoneRelationship Address *Please notify this Agency immediately if any of the emergency contact information changes.
Explanation and Instruction:
Our company policy requires all employees who have direct contact with patients in the home setting to submit a statement from an appropriately licensed health care professional, based on an exam performed within the last twelve months. The employee must show no apparen signs or symptoms of communicable disease.
Statement to be signed by a Physician or appropriately licensed Healthcare professional.Name was examined by me on MM slash DD slash YYYY He/She is in adequate health to perform home health duties and show no apparent signs or symptoms of communicable disease. Professional SignatureDate MM slash DD slash YYYY Address Phone numberA PPD test was done in this office on MM slash DD slash YYYY by and read on MM slash DD slash YYYY by Rt. Forearm Lt. forearm Result If redness present, size/description Manufacturer name Lot number
Employee Printed Name
If the answer is YES, please answer the following:
a. Silicosis (lung disease) b. Gastrectomy c. Intestinal Bypass d. Weight 10% or more below ideal body weight e. Chronic Renal Disease f. Diabetes Mellitus g. Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy h. Hematologic Disorder i.e. leukemia or lymphoma i. Exposure to HIV or AIDS j. Other malignancies
Baseline Individual TB Risk AssessmentAnswer “Yes” or “No”. Employee should be considered at risk for TB if any of the following statements are marked “Yes”. Temporary or permanent residence of > 1 month in a country with a high TB rate (any country other than the U.S., Canada, Australia, New Zealand, and those in Northern or Western Europe) Current or planned immunosuppression, including HIV infection, organ transplant recipient, treatment with a TNF alpha antagonist, chronic steroids, or other immunosuppressive medication. Close contact with someone who has had infectious TB disease since the last TB test Employee SignatureDate MM slash DD slash YYYY Reviewed by SignatureDate MM slash DD slash YYYY
I, acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself.
Request that I receive the Hepatitis vaccine Refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me. Provide written proof of immunity (attach) Provide written proof of previous vaccination (attach) Provide written proof of medical contraindication (attach)
Attach Files Drop files here or Select files Max. file size: 512 MB.
SignatureDate MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
