Application for Employment

Last Name:*
First Name:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Mobile Phone:*
Are You 18 or older?:*
 Yes
 NO
Position Applying for:*
Position:*
 Full Time
 Part Time
 Part Time Per Visit
 Pool
Shift:
 Day
 Night
 Evening
 Weekend
Salary Requirements:
Date Available:
If you are not a US citizen, have you the legal right to remain permanently in the US?
 Yes
 No
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
 Yes
 No
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or Released from confinement following a conviction for any criminal offense within the past 7 years?*
 Yes
 No
If yes, give date, place and nature of each such conviction.
Educational History:
List professional licenses you possess. Indicate type of license, number and state:
List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.
List languages spoken other than English:
List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc.:
Emergency Notification & Relationship:
____________________________________________________________________
Work History - Feel free to email further work history to MGarcia@LivingTreeOfLife.net
Company Name:
Company Address:
Phone Number:
Supervisor's Name:
Date Started/Date Left:
Type of Business:
Salary:
Reason for Leaving:
OK to Contact Supervisor:
 Yes
 No
Describe your job title, responsibilities and accomplishments:
____________________________________________________________________
Company Name:
Company Address:
Phone Number:
Supervisor's Name:
Date Started/Date Left:
Type of Business:
Salary:
Reason for Leaving:
OK to Contact Supervisor:
 Yes
 No
Describe your job title, responsibilities and accomplishments:
____________________________________________________________________
List Personal References (Name, Phone,& Relationship):
____________________________________________________________________
Please Review and Initial at the Bottom:
In Making Application for Employment:
* I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offfered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
* I understand tat an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
* I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.
* I understand, if I am an unlicensed person who has direct patient contract, that the agency will perform a criminal history check per State Regulations.
Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and if available, faculty appraisals. I also authorize any appropriate licensing board so release full information concerning my license status and my license history.
Date:*
Initial Here:*


Submit