Please provide the following information Once you have finished click on submit and you will see a completed, printable version. You can then sign and date it and mail it in.

 

APPLICATION
FOR EMPLOYMENT
POSITION SALARY DESIRED DATE AVAILABLE PHONE NUMBER SOCIAL SECURITY NUMBER
 
LAST NAME FIRST NAME MIDDLE
 
STREET ADDRESS CITY STATE ZIP
 
HAVE YOU EVER BEEN EMPLOYED HERE BEFORE?          YES     NO IF YES, GIVE DATE(S):
ARE YOU AT LEAST 18 YEARS OLD?          YES     NO
ARE YOU A:
U.S. Citizen
Permanent Resident
Other
HAVE YOU EVER BEEN CONVICTED OR ARE PRESENTLY CHARGED WITH ANY VIOLATION OF THE LAW?       YES     NO
IF YES, PLEASE EXPLAIN:
ARE THERE ANY DAYS OR HOURS YOU WOULD BE UNABLE OR UNWILLING TO WORK?       YES     NO
IF YES, PLEASE SPECIFY:
HAVE YOU EVER SERVED IN THE ARMED FORCES?       YES     NO       BRANCH:
DATES: FROM TO        TYPE OF TRAINING:
EDUCATION
 
NAME AND ADDRESS OF INSTITUTION

DATES

GRADUATED
DEGREE RECEIVED
AREAS OF SPECIALIZATION
HIGH SCHOOL

FROM

TO

YES     NO     
COLLEGE

FROM

TO

YES     NO    
ADDITIONAL EDUCATION

FROM

TO

YES     NO    
PROFESSIONAL LICENSES AND/OR CERTIFICATES
TYPE

STATE ISSUED.

DATE ISSUED
EXPIRES
NUMBER

REFERENCES     GIVE THREE WORK RELATED REFERENCES (NOT RELATIVES)
NAME

TELEPHONE NUMBER

OCCUPATION
YEARS KNOWN

EMPLOYMENT HISTORY
EMPLOYER
EMPLOYED
FROM
EMPLOYED
TO
YOUR DUTIES
ADDRESS
POSITION HELD HOURS/WEEK
SALARY
STARTING
SALARY
FINAL
NAME AND TITLE OF SUPERVISOR PHONE NUMBER
REASON FOR LEAVING

MAY WE CONTACT?

YES     NO    

If employed under any other name, please state:
EMPLOYER
EMPLOYED
FROM
EMPLOYED
TO
YOUR DUTIES
ADDRESS
POSITION HELD HOURS/WEEK
SALARY
STARTING
SALARY
FINAL
NAME AND TITLE OF SUPERVISOR PHONE NUMBER
REASON FOR LEAVING

MAY WE CONTACT?

YES     NO    

If employed under any other name, please state:
EMPLOYER
EMPLOYED
FROM
EMPLOYED
TO
YOUR DUTIES
ADDRESS
POSITION HELD HOURS/WEEK
SALARY
STARTING
SALARY
FINAL
NAME AND TITLE OF SUPERVISOR PHONE NUMBER
REASON FOR LEAVING

MAY WE CONTACT?

YES     NO    

If employed under any other name, please state:
EMPLOYER
EMPLOYED
FROM
EMPLOYED
TO
YOUR DUTIES
ADDRESS
POSITION HELD HOURS/WEEK
SALARY
STARTING
SALARY
FINAL
NAME AND TITLE OF SUPERVISOR PHONE NUMBER
REASON FOR LEAVING

MAY WE CONTACT?

YES     NO    

If employed under any other name, please state:

ADDITIONAL INFORMATION

 

APPLICANTS CERTIFICATION AND AGREEMENT

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements may result in dismissal.I authorize the company to make an investigation of any of the facts set forth in this application.

I understand that employment at this company is "at will", which means that either I or the company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis.

 

Date:___________________________     Applicant's Signature_____________________________________________________________________

 

CARE PARTNERS, LLC IS AN EQUAL OPPORTUNITY EMPLOYER AND BASES ALL EMPLOYMENT DECISIONS ON THE QUALIFICATIONS OF EACH APPLICANT. THEY DO NOT DISCRIMINATE AGAINST ANY EMPLOYEE OR APPLICANT ON THE GROUNDS OF RACE, COLOR, SEX, RELIGION, NATIONAL ORIGIN, DISABILITY, AGE OR VETERAN STATUS.

DO NOT WRITE BELOW THIS LINE
INTERVIEW DATE    _____/_____/_____ INTERVIEWERS INITIALS__________________________
DATE OF HIRE    _____/_____/_____  
POSITION_____________________________________________ STATUS___________________________
RATE OF PAY_______________________  

4860 Cox Road, Suite 200 Innsbrook Corporate Center Glan Allen, Virginia 2306

Phone (804) 935-8585 Fax (804) 351-7797 E-mail: Care_Partners@msn.com