Careers Application

Date:

Full Name:

Social Security Number:

Email:

Cell Phone:

Are you at least 18 years of age?

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ADDRESS

Street:

City:

State:

Zip Code:

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CITIZENSHIP

Are you a citizen of the USA?

Yes

No

If “NO”, under what authority will you be working in the USA?

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EMPLOYMENT

Have you ever been employed here before?

Yes

No

If yes, when?

If yes, what position?

Have you ever applied for a job here before?

Yes

No

If yes, when?

How were you referred to Network, Inc.?

Do you have any relatives working for us?

Yes

No

If yes, who?

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EDUCATION, LICENSES, AND CERTIFICATIONS

Highest Level of Education Completed:

Name of School:

List any professional licenses and/or certifications:

Check off current trainings:

FA

CPR

PMT

DDS Med. Certification

What position are you applying for?

Direct Support Staff

LPN

RN

Other (please indicate title in box below)

If Other, what position?

Salary Requirements:

Availability:

Full Time

Part Time

Relief

Temp

What shifts are you able to work?

1st Shift

2nd Shift

3rd Shift

Weekends

What days are you available to work?

What towns are you willing to work?

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TELL US ABOUT YOUR WORK EXPERIENCE

Name of Current or Most Recent Employer

Address:

Phone:

Job Title:

Supervisor's Name:

How long were you employed there (dates included):

Job Duties (give details)

Reason for leaving:

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Please answer the following questions.

Your answers will be held in strict confidence, except as needed to process your application.

Are there any criminal charges currently pending against you?

Yes

No

If yes, when?

If yes, where?

Describe:

Do you currently use illegal drugs?

Do you possess a valid driver's license?

Yes

No

Are you comfortable assisting with hygiene needs?

Are you physically able to lift, transfer, and support individuals?

Did you graduate:

If yes, check one:

GED

Diploma

Degree

What name did you graduate under:

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EEO APPLICANT DATA FORM

Important information for all applicants: To enable Network to meet government reporting regulations and to maintain an Affirmative Action Plan, applicants are

requested to complete this personal data sheet.

Information will be used for government reporting purposes and will be

detached and kept separate from your job application. This information will not be used as selection criteria and will be treated as personal and confidential. Your

decision or refusal to provide the requested information will not subject you to any

adverse treatment. Your voluntary cooperation will be appreciated.

Sex:

Race/Ethnic Category:

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I am a qualified handicapped individual who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) is regarded as having such impairment and (4) is capable (qualified) of performing a particular job with reasonable accommodation to my handicap.

Field label

Yes

No

Employment Application

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