Absolute Care Employment Application

 

PERSONAL INFORMATION                                              

Date of Application: ___________________          Social Security Number: _________________

Male or Female (circle one)

Email address: _____________________________________________

How often do you check your email _______________________________________________

Name: _____________________________________________________­_______________ 

                          Last                                       First                              Middle

Address: _____________________________________________________________________

                   No.             Street             Apt#                        City                 State                 Zip

Telephone Number (best way to reach you) ______________________________________

Position(s) applied for: _____________________________     Rate of pay expected $ _________

                             

Date available to start work: _____________

Have you ever worked for this agency before:  Yes/No (circle one)

Have you ever applied for a position with this agency before: Yes/No (circle one)

How did you learn of this opening? If friend, list name of friend below: ____________________________________________________________________________

List friends or relatives working for this agency: ____________________________________________________________________________

 

EMPLOYMENT HISTORY

Name of Employer: __________________________________

Telephone No. (      )  __________________________________

Complete Address: _____________________________________________________________

Supervisor’s Name: __________________________  Title: ______________________________

Job Title: _____________________________________   Dates of Employment: _____ to _____

Salary: beginning ___________  ending __________             Full/Part Time (Circle one)

Describe Responsibilities: ____________________________________________________________________________

____________________________________________________________________________

Reason for Leaving: ____________________________________________________________________________

 

 

Name of Employer: __________________________________ 

Telephone No. (      )  __________

Complete Address: _____________________________________________________________

Supervisor’s Name: __________________________  Title: ______________________________

Job Title: _____________________________________   Dates of Employment: _____ to _____

Salary: beginning ___________  ending __________             Full/Part Time (Circle one)

Describe Responsibilities: ____________________________________________________________________________

____________________________________________________________________________

Reason for Leaving: ____________________________________________________________________________

 

 

Name of Employer: __________________________________ 

Telephone No. (      )  __________

Complete Address: _____________________________________________________________

Supervisor’s Name: __________________________  Title: ______________________________

Job Title: _____________________________________   Dates of Employment: _____ to _____

Salary: beginning ___________  ending __________             Full/Part Time (Circle one)

Describe Responsibilities: ____________________________________________________________________________

____________________________________________________________________________

Reason for Leaving: ____________________________________________________________________________

 

 

List the employers we may NOT call:

________________________________________________________

 

 

EDUCATION

Type	Complete name and address	Years Completed	Graduated?	Degree?	Major
High School	`	1  2  3  4	Yes     No	`	`
College	`	1  2  3  4	Yes     No	`	`
Post Graduate	`	1  2  3  4	Yes     No	`	`
Business or Trade	`	1  2  3  4	Yes     No	`	`
Other	`	1  2  3  4	Yes     No	`	`

 

CERTIFICATION/LICENSURE REGRISTRATION

For many positions, state certification, licensure or registration requirements MUST be met.  Be sure to enclose copies of the applicable document(s) and complete the information below as it relates to the position(s) for which you have applied

Type of Certificate/Registration/License:	Authorizing Board or Agency/Auth. State	Expiration/Renewal Date
`	`	`
`	`	`
`	`	`

 

 MILITARY SERVICE RECORD

Have you ever served in the armed services?     Yes     No

If yes, please submit a copy of your DD-214

Is a copy of your DD-214 enclosed?     Yes     No

MISCELLANEOUS

1. Have you ever been convicted of or pleaded guilty to any of the following?

A.  A felony contained in the Ohio Revised Code:          Yes    No

B.  A crime contained in the Ohio Revised Code constituting a misdemeanor of the first degree on the first offense and a felony on subsequent offenses:      Yes    No

C.  A violation of an existing or former law of Ohio, any other state, or the United Staes, which offense is substantially equivalent to any of the offenses described in (A) or (B) above:     Yes   No

2.  Have you ever been discharged or requested to resign from a position?    Yes   No

3.  Have you ever had a certificate, license or registration revoked or suspended?   Yes   No

4.  Can you perform the job-related requirements of the specific job(s) for which you are applying?    Yes   No

If you answered YES to questions 1,2 or 3, or NO to question 4; please explain FULLY, indicating (by number) to which question you are responding: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

REFERENCES

List three references, excluding former employers and relatives, who this agency has permission to contact.

Name:	Occupation:	Address:	Telephone Number:
1.	`	`	(     )
2.	`	`	(     )
3.	`	`	(     )

ADDITIONAL INFORMATION

Please summarize other experiences, skills, or qualifications which you feel would qualify you for the position(s) for which you have applied.

If available, please include copies of:  CPR and First Aid Certification, Current Drivers License, Auto Insurance, and any other applicable certifications.

AVAILABILITY

Please list your hours of availability:

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
`	`	`	`	`	`	`
`	`	`	`	`	`	`

 

 

Applicant’s Signature: ___________________________ __________    Date: ________