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Application for Employment
Personal Information
First Name:
Last Name:
Middle Name:
Street Address:
City:
State:
Zip:
Home Phone:	EX: 123-456-7890
Work Phone:	EX: 123-456-7890
Email Address:
Are you authorized to work in the United States? (Verification will be required upon hire.) Yes No
Are you over 18 years of age? (Verification will be required upon hire.) Yes No
Job Interest
Position desired:	full time part time days evenings weekends temporary/seasonal
Starting Date:
Pay per hour expected:
Average # of hours per week desired:
How were you referred to us?
Education - Licensure - Certification
Graduate School
Graduate school name:
Graduate school address:
Course of study:
Number of years completed:
Did you graduate?	yes no
Name of degree, certificate or diploma:
College
College name:
College address:
Course of study:
Number of years completed:
Did you graduate?	yes no
Name of degree, certificate or diploma:
Business/Trade/Technical
School name:
School address:
Course of study:
Number of years completed:
Did you graduate?	yes no
Name of degree, certificate or diploma:
High School
School name:
School address:
Course of study:
Number of years completed:
Did you graduate?	yes no
Name of degree, certificate or diploma:
License, Registration, Certification
1. Type:
License #:
Expiration date:
State:
2. Type:
Certification#:
Expiration date:
State:
Other specialized training (i.e. technical training, etc.)
Please describe:
Office skills (i.e. types of office machines and software you can operate)
Please describe:
References (List three prior employees or supervisors who can comment on your abilities.)
Reference 1
Name:
Company Name:
Telephone:	EX: 123-456-7890
Title/Position:
How long have you worked together?
Reference 2
Name:
Company Name:
Telephone:	EX: 123-456-7890
Title/Position:
How long have you worked together?
Reference 3
Name:
Company Name:
Telephone:	EX: 123-456-7890
Title/Position:
How long have you worked together?
Employment History
Employer 1
Employer
May we contact this employer as a reference?	yes no
Telephone:	EX: 123-456-7890
Address:
Dates of employment (mm/yy):
Name of Supervisor:
Rate Pay	Start: End:
Describe your job title and responsibilities:
Reason for leaving:
Employer 2
Employer
May we contact this employer as a reference?	yes no
Telephone:	EX: 123-456-7890
Address:
Dates of employment (mm/yy):
Name of Supervisor:
Rate Pay	Start: End:
Describe your job title and responsibilities:
Reason for leaving:
Employer 3
Employer
May we contact this employer as a reference?	yes no
Telephone:	EX: 123-456-7890
Address:
Dates of employment (mm/yy):
Name of Supervisor:
Rate Pay	Start: End:
Describe your job title and responsibilities:
Reason for leaving:
Other Information
Have you ever been convicted of a felony? yes no
If yes, give details:
In answering the following questions, do not included a first conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace.
Have you ever been convicted of a misdemeanor within the past five years? yes no
If yes, give details:
Have you ever been convicted of a misdemeanor five or more years ago? yes no
If yes, give details:
PLEASE READ CAREFULLY I certify that the information provided by me in this application is correct and complete to the best of my knowledge. I understand that any false information or omission of fact may disqualify me for employment and may be cause of dismissal at a later date. I understand that employment is conditional upon satisfactory replies from my references. I understand and agree that any offer of employment is contingent upon satisfactory completion of SHC pre-employment investigation which includes but is not limited to health assessment, criminal history check (CORI), educational and work verification, reference checks, consumer report and any investigating required by state laws. I understand that acceptance of an offer of employment does not create a contractual obligation and that either party may terminate the employment relationship, at will, at any time and for any reason or no reason. Standards Home Care, is an Equal Opportunity Employer and does not unlawfully discriminate in employment decisions because of race, religion, color, national origin, age, disability, sex, or veteran. I have read, understood, and agree with the before mentioned statements.

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100 Cummings Center
Suite 235 C
Beverly, MA 01915

Phone: 978-922-0088
Fax: 978-922-0422

info@standardsincare.com

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© 2011 Standards Home Care

Standards Home Care, does not discriminate against any person on the basis of race, color, religious creed, nations origin, disability, are or sexual orientation in admissions, treatment or participation in its programs, services and activities or in employment.