Employment Application – Light Of Hope Health Services

Today's Date

First Name

Last Name

Preferred Name/Nickname

Street Address

City

State

Zip Code

Phone

Alternate Phone

Email Address

Are you interested in:

Full Time Part Time Temporary

What schedules would you prefer?

Weekdays Weekends Evenings Nights

How did you hear about us?

Walk In Referral Advertisement Other

If Referral, Name

If Advertisement, Where?

If Other, Please Specify

Have you worked for this company before?

No Yes

Dates

Date Available to Start

Salary Desired

Can you provide proof of eligibility to work in the U.S.?

Have you ever been convicted of a felony?

Yes No

If yes, please explain

Employer Name

Position / Job Title

From

Employer Address

City

State

Zip Code

Supervisor

Phone

Type of Business

Termination

Voluntary Involuntary

Reason for Leaving

Duties / Responsibilities

Employer Name

Position / Job Title

From

Employer Address

City

State

Zip Code

Supervisor

Phone

Type of Business

Termination

Voluntary Involuntary

Reason for Leaving

Duties / Responsibilities

Employer Name

Position / Job Title

From

Employer Address

City

State

Zip Code

Supervisor

Phone

Type of Business

Termination

Voluntary Involuntary

Reason for Leaving

Duties / Responsibilities

High School or Prep

Major Subject

Did You Graduate?

Yes No

Type of Degree or Diploma

College

Major Subject

Did You Graduate?

Yes No

Type of Degree or Diploma

College or Graduate

Major Subject

Did You Graduate?

Yes No

Type of Degree or Diploma

Other

Major Subject

Did You Graduate?

Yes No

Type of Degree or Diploma

Designation

Organization Granting Designation

Date Completed

Designation

Organization Granting Designation

Date Completed

Type of License

State Granting License

License Number

Type of License

State Granting License

License Number

Reference Name

Relationship

Company

Phone / Alternate Phone

Reference Name

Relationship

Company

Phone / Alternate Phone

Reference Name

Relationship

Company

Phone / Alternate Phone

Applicant Certification I certify that the information I have provided in this employment application is true and complete to the best of my knowledge. I understand that any false statement or omission may result in the rejection of my application or, if employed, termination of my employment. I understand that submission of this application does not guarantee employment and that, if hired, my employment is subject to the policies of the employer. This summary is provided for applicants to acknowledge before submitting the application

Agreement

I certify that I have read and agree to the Applicant Certification above.

Electronic Signature

Date Signed