Application For Employment

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PLEASE COMPLETE BY PRINTING IN INK OR TYPING. COMPLETE ALL QUESTIONS and SIGN YOUR NAME ON THE LAST PAGE.

PERSONAL INFORMATION

1. PERSONAL INFORMATION

Last Name*

First Name*

Middle Name*

ADDRESS

ADDRESS

House Number

Street

Apt.

City

State

ZIP Code

TELEPHONE

TELEPHONE

Work

Home

POSITION APPLIED FOR

COMPENSATION DESIRED

DATE YOU CAN START

ARE YOU WILLING TO WORK PART TIME?

Ye

No

FULL TIME YES

Yes

No

ARE YOU WILLING TO START WORK AS PART TIME OR TEMPORARY WITHOUT BENEFITS FOR A PROBATIONARY PERIOD?

Yes

No

DO YOU CURRENTLY HAVE HEALTH INSURANCE?

Yes

No

DENTAL COVERAGE?

Yes

No

NAME OF INSURANCE PROVIDER & POLICY NUMBERS

EDUCATION AND SKILLS

2. EDUCATION AND SKILLS

High School

HIGH SCHOOL

NAME OF SCHOOL CITY AND STATE

MAJOR SUBJECTS OR TYPE OF COURSES

LAST YEAR COMPLETED

9

10

11

12

DID YOU GRADUATE?

COLLEGE OR UNIVERSITY

COLLEGE OR UNIVERSITY

NAME OF SCHOOL CITY AND STATE

MAJOR SUBJECTS OR TYPE OF COURSES

LAST YEAR COMPLETED

1

2

3

4

DID YOU GRADUATE?

COLLEGE OR UNIVERSITY

COLLEGE OR UNIVERSITY

NAME OF SCHOOL CITY AND STATE

MAJOR SUBJECTS OR TYPE OF COURSES

LAST YEAR COMPLETED

1

2

3

4

DID YOU GRADUATE?

ADDITIONAL SCHOOLING/SPECIALIZED TRAINING

ADDITIONAL SCHOOLING/SPECIALIZED TRAINING

NAME OF SCHOOL CITY AND STATE

MAJOR SUBJECTS OR TYPE OF COURSES

LAST YEAR COMPLETED

DID YOU GRADUATE?

LICENSE/CERTIFICATE/REGISTRATION

NUMBER

PROFESSIONAL LICENSES, CERTIFICATION OR REGISTRATION AND DRIVERS LICENSE

PROFESSIONAL LICENSES, CERTIFICATION OR REGISTRATION AND DRIVERS LICENSE

ISSUED BY:

EXPIRATION DATE

ISSUED BY:

EXPIRATION DATE

ISSUED BY:

EXPIRATION DATE

WORK EXPERIENCE

3. WORK EXPERIENCE

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Please give your full employment record, starting with your current or most recent employment and going back at least 10 years. Include military service as a part of the mployment record. Use additional sheets if necessary.

EMPLOYER

FROM

TO

ADDRESS

TELEPHONE NUMBER

JOB TITLE

SUPERVISOR'S NAME

DESCRIBE YOUR DUTIES AND RESPONSIBILITIES

STARTING SALARY

ENDING SALARY

REASON FOR LEAVING

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EMPLOYER

FROM

TO

ADDRESS

TELEPHONE NUMBER

JOB TITLE

SUPERVISOR'S NAME

DESCRIBE YOUR DUTIES AND RESPONSIBILITIES

STARTING SALARY

ENDING SALARY

REASON FOR LEAVING

---------------------------------

---------------------------------

EMPLOYER

FROM

TO

ADDRESS

TELEPHONE NUMBER

JOB TITLE

SUPERVISOR'S NAME

DESCRIBE YOUR DUTIES AND RESPONSIBILITIES

STARTING SALARY

ENDING SALARY

REASON FOR LEAVING

MAY WE CONTACT YOUR PRESENT EMPLOYER?

Ye

No

GENERAL INFORMATION

GENERAL INFORMATION

DO YOU HAVE AN AUTO?

Yes

No

DO YOU HAVE CURRENT AUTO INSURANCE? (IF YOUR JOB REQUIRES YOU DRIVING YOUR OWN VEHICLE WE NEED A COPY OF YOUR INSURANCE CARD.)

Yes

No

ARE YOU 18 YEARS OF AGE OR OLDER?

Yes

No

DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES? (SUCCESSFUL APPLICANTS WILL BE REQUIRED TO PROVE IDENTITY AND ELIGIBILITY FOR EMPLOYMENT.)

Yes

No

HAVE YOU EVER BEEN EMPLOYED OR ATTENDED SCHOOL USING ANY OTHER NAME?

Yes

No

IF YES, PLEASE EXPLAIN

HAVE YOU EVER BEEN CONVICTED, PLEAD GUILTY, OR NO CONTEST, OR FORFEITED BOND OR BAIL FOR ANY CRIME OTHER THAN TRAFFIC VIOLATIONS?

Yes

No

IF YES, PLEASE EXPLAIN

(Conviction of a crime is not an automatic bar to employment. Factors such as the nature and gravity of the crime, the length of time that has passed since the conviction and/or completion of any sentence, and the nature of the job for which you have applied will be considered.)

In Home Caregivers (this question only)

In Home Caregivers (this question only)

HAVE YOU EVER BEEN ACCUSED, FOUND, AND OR CONVICTED OF ABUSE?

Yes

No

IF YES, PLEASE EXPLAIN

ARE YOU ABLE TO PERFORM THE PRIMARY DUTIES OF THE JOB AS OUTLINED IN THE NEWSPAPER ADVERTISEMENT, POSTING, JOB DESCRIPTION, ANNOUNCEMENT, ETC., WITH OR WITHOUT REASONABLE ACCOMMODATION?

Yes

No

IF NO, PLEASE EXPLAIN

DO YOU HAVE ANY EMPLOYMENT RESTRICTIONS RESULTING FROM A NON-COMPETE OR CONFIDENTIALITY AGREEMENT?

Y

No

WHERE DID YOU LEARN ABOUT THIS EMPLOYMENT OPPORTUNITY?

PLEASE USE THE SPACE BELOW TO PROVIDE ANY ADDITIONAL INFORMATION (FOR EXAMPLE, SPECIFIC SKILLS, ADDITIONAL EMPLOYERS, PERIODS OF TIME NOT WORKED, ETC.)

PLEASE READ CAREFULLY BEFORE SIGNING.

I certify that I have answered the above questions truthfully and have not withheld any information relative to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements or omissions of the application information, attachments, and supporting documents generally will result in denial of employment or immediate termination, if discovered after hire.

It is the policy of HR Alliance, Inc. to afford equal opportunity to all employees and applicants without regard to race, age, religion, color, sex, national origin, physical or mental disability, marital or veteran status, sexual orientation, or any other classification protected by federal, state or local law.

I authorize HR Alliance, Inc., or its third party, to conduct any necessary investigation concerning my employment, employment practices and behavior, current and past.

I authorize HR Alliance, Inc. to investigate whether I have a criminal record of convictions, and, if so, the nature of such convictions and all the surrounding circumstances of the conviction. I understand that any criminal background check will focus on convictions, and that a criminal record will not necessarily disqualify me from employment.

If hired, I agree to abide by the rules and policies of HR Alliance, Inc. I understand that my employment and compensation can be terminated at any time, with or without cause, and with or without notice, at the option of HR Alliance, Inc. or myself. I understand that the president of HR Alliance, Inc. is the only person who has the authority to create any other terms of employment and/or to enter into any employment contract and that all such contracts must be in writing and signed by both parties. However, I also understand that unless otherwise stated in an employment contract, the company may change, withdraw and interpret other policies (including wages, hours, and working conditions) as it deems appropriate.

I acknowledge reading and understanding the foregoing statements.

SIGNATURE

DATE

Phone

Fax

Email

Business Hours

Location