EmailMe Form - Chapel Grove Job Application

Name *

First Last

Email *

Rate of Pay Expected

$ Dollars . Cents

Phone *

### - ### - ####

Alternate Phone

### - ### - ####

Your Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Do you have a relationship to any current/previous employees?

List position(s) applied for:

Applicants are considered for all positions, without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job related medical condition or handicap.

EDUCATION

	Elementary	High School	College	Graduate / Professional
School Name
Years Completed
Diploma/Degree/Studies

Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience.

Give name, address and telepone number of three professional references

1. Name

First Last

Phone

### - ### - ####

Address

2. Name

First Last

Phone

### - ### - ####

Address

3. Name

First Last

Phone

### - ### - ####

Address

If employed and you are under 18, can you furnish a work permit?

Yes

No

Have you filed an application here before?

Yes

No

If yes, give date

Are you employed now?

Yes

No

May we contact your present employer?

Yes

No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?

Yes

No

If yes, please explain.

(Proof of citizenship or immigration status may be required upon employment.)

Have you been convicted of a crime that may hinder you from employment

Yes

No

If yes, please explain.

On what date would you be available to work?

MM / DD / YY

Veteran of the U.S. Military service?

Yes

No

If yes, list branch.

Employment Experience

Employer 1


Company Name / Supervisor
Address / Phone
Start / End Date
Start / End Salary
Job Title / Work Performed
Reason for Leaving

Employer 2


Company Name / Supervisor
Address / Phone
Start / End Date
Start / End Salary
Job Title / Work Performed
Reason for Leaving

Employer 3


Company Name / Supervisor
Address / Phone
Start / End Date
Start / End Salary
Job Title / Work Performed
Reason for Leaving

Employer 4


Company Name / Supervisor
Address / Phone
Start / End Date
Start / End Salary
Job Title / Work Performed
Reason for Leaving

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

I understand, also, that I am required to abide by all rules and regulations of the Company. If I am employed, I understand and agree that when my employment is terminated by retirement or otherwise, I must return all of Employer's property in my custody, including office keys, manuals and sales material before I am entitled to final payment of any amounts due me on separation.

I acknowledge that I will be required to shadow another employee prior to being hired and agree to maintain confidentiality and privacy regarding any and all resident information.

Do you agree with the statement above?

Yes

No