Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration status will be required upon employment.) Yes No Have you ever been convicted of a crime?
Yes No
Please answer if you are a licensed health care professional: Have you ever been denied licensure or had any health care field license suspended or revoked? Yes No If yes, please indicate date: _____________________________ License/Certification Number ____________________________________ State ______________ EDUCATIONAL BACKGROUND High School Name Graduated Yes No College Name
Address If yes, do you have a diploma ____ or GED ____ Address
Course or Major
Graduated Yes No
Diploma/Degree
EMPLOYMENT HISTORY – List three (3) employers, assignments or volunteer activities starting with the most recent, including military experience. Employer Phone Address Position
Dates Employed (To/From)
Immediate Manager/Supervisor and Title Description of Duties
Reason for Leaving May we contact for reference? Yes No
34 Franklin Park West, St. Albans, Vermont 05478 Phone: (802) 527-0548 Fax: (802) 527-2399
Rate of Pay
Application for Employment Employer
Page 2 Phone
Address Position
Dates Employed (To/From)
Rate of Pay
Immediate Manager/Supervisor and Title Description of Duties
Reason for Leaving May we contact for reference? Yes No Employer
Phone
Address Position
Dates Employed (To/From)
Rate of Pay
Immediate Manager/Supervisor and Title Description of Duties
Reason for Leaving May we contact for reference? Yes No SKILLS AND QUALIFICATIONS – Please use the space below to summarize any special training, skills, licenses, certificates and/or additional information to help best describe your skills and qualifications for this position:
REFERENCES – Give names of three (3) persons, NOT relatives, who can be contacted for references: Name Phone Address Name
Phone
Address Name
Phone
Address
All of the foregoing information I have supplied in this application is a full and complete statement of the facts and it is understood that if any falsification will constitute grounds for dismissal upon discovery thereof.
Signature of Applicant
Date
Please return application to: CarePartners Adult Day Center 34 Franklin Park West, St. Albans, Vermont, 05478
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and/or received probation or deferred adjudication? yes no. If yes, please explain: (Conviction of a felony is not an automatic bar to employment. The district will ...
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Please complete this application by typing or printing in ink. ... Do you need an accommodation to participate in the application or interview ... Company Name.
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DRUG-FREE WORKPLACE POLICY. Intermountain Aquatics, Inc. intends to help provide a safe and drug-free work environment for our clients and our employees. With this goal in mind and because of the serious drug abuse problem in today's workplace, we ar
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