Employment Form

* = Required Information

This agency is an equal opportunity employer. Applicants will be considered for employment without regard to race, religion, color, sex, marital status, sexual orientation, age, national origin, ancestry, mental or physical disability, medical condition, veteran status, citizenship, or any other characteristic protected by state or federal law or local ordinance.

PERSONAL INFORMATION

Last Name*

First Name*

Middle Name*

Home Address *

Apartment #

State

City

Zip Code

Mailing Address (if different from above)

City

State

Zip Code

Home Telephone *

List Other Name(s) Used

Are you at least 18 years old?

Yes

If hired, can you present evidence of your legal right to work in this country?

Yes

EMPLOYMENT INFORMATION

Position Desired

Salary Desired

Date You Can Start

What days and hours are you available to work?

Monday

From

Tuesday

From

Wednesday

From

Thursday

From

Friday

From

Saturday

From

Sunday

From

EDUCATION, TRAINING AND SKILLS

High School

Name of School

Location

Number Years Attended

Degree Obtained

College

Name of School

Location

Number Years Attended

Degree Obtained

Graduate

Name of School

Location

Number Years Attended

Degree Obtained

Vocational

Name of School

Location

Number Years Attended

Degree Obtained

Other

Name of School

Location

Number Years Attended

Degree Obtained

SKILLS, TRAINING AND QUALIFICATIONS (please check all that applies)

EMPLOYMENT HISTORY (start with the most recent)

Company Name

Position

Address and Telephone Number

Employment Dates

Name of Supervisor

Salary

Job Duties

Reason for Leaving

Company Name

Position

Address and Telephone Number

Employment Dates

Name of Supervisor

Salary

Job Duties

Reason for Leaving

Company Name

Position

Address and Telephone Number

Employment Dates

Name of Supervisor

Salary

Job Duties

Reason for Leaving

Company Name

Position

Address and Telephone Number

Employment Dates

Name of Supervisor

Salary

Job Duties

Reason for Leaving

REFERENCES

List below two persons not related to you, from either a business or academic settings who have knowledge of your performance abilities within the last three years.

1. Reference Name

Relationship

Years Known

Company/Institution

Telephone

2. Reference Name

Relationship

Years Known

Company/Institution

Telephone

3. Reference Name

Relationship

Years Known

Company/Institution

Telephone

LICENSING INFORMATION

License/Certificate Name

Expiration Date

State Issued

License/Certificate Name

Expiration Date

State Issued

License/Certificate Name

Expiration Date

State Issued

THE FOLLOWING SECTION IS FOR EMPLOYMENT WITHIN THE HEALTH CARE INDUSTRY IN CALIFORNIA

Please answer the following only if:

1. The position for which you are applying will provide you access to patients. Have you ever been arrested for a sex related crime?

Yes

If yes, please explain.

2. The position for which you are applying will provide you with access to drugs or medications. Have you ever been arrested for a drug related crime?

Yes

If yes, please explain.

NOTICE TO APPLICANTS

In completing this application for employment, I understand and agree that:

Acceptance of this application does not mean that I will be offered a position with THE AGENCY.
I hereby certify that the information contained in this application is true and accurate. I acknowledge that my providing of false or misleading information in this application or in any employment interview will result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.
I hereby authorize THE AGENCY to conduct reference check, investigation into my background, finances, prior employment, criminal history, or any other aspect of my background deemed important to company. I hereby release THE AGENCY and all persons contacted by THE AGENCY from any and all liabilities for any damages that may result from obtaining or furnishing such information to THE AGENCY or any of its agents, employees, or representatives.
I understand that I will have to provide certain identifying information to company, including my date of birth and social security number; and will have to provide documentary evidence to establish my identity, age and my right to work in the United States.

AGREEMENT FOR AT-WILL EMPLOYMENT

If I am hired by the AGENCY, I understand that my employment will be "at- will" meaning that I can leave my employment at any time and for any reason, and that my employment may be terminated at any time and for any reason. I maybe asked to sign an employment agreement as a condition of my employment. I will be required to read an Employee Handbook and safety program, acknowledging receipt of both, and agreed to comply with all policies and procedures of the company.

Signature

Date