Application For Employment

Please print; use additional sheets if necessary. Conditions of employment are stated at the end of this form. Please read carefully before you sign and submit this application.
Date of application:(*)
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Position(s) applied for:(*)
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PERSONAL INFORMATION
First Name(*)
Please type your first name.

Last Name(*)
Please type your last name.

Middle Name
Please type your last name.

Street Address:(*)
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City:(*)
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State:(*)
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Zip:(*)
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Phone:(*)
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E-mail(*)
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SS #:(*)
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Are any of your relatives presently employees, board members, or service recipients with our agency?(*)
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If yes, name of relative:
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Have you ever worked for our agency before?(*)
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If yes, position title and dates of employment:
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Have you ever applied for employment with our agency before?(*)
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If yes, when:
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Referral Source
(if referred by a current employee list their name):
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GENERAL INFORMATION
Are you at least 21 years of age?(*)
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Are you legally eligible for employment in the United States?(*)
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(Note: Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment with our agency. Employment is subject to verification of U.S. citizenship or authorized alien status in accordance with the Immigration Reform and Control Act of 1986.)

Have you ever been discharged from any employment or asked to resign?(*)
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If yes, please explain:
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Do you have a valid state driver’s license?(*)
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Have you been convicted of more than three traffic violations in the past year?(*)
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List all traffic violations in the past five years which resulted in a conviction, or a guilty plea:
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List all at-fault traffic accidents in the past five years:
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POSITION SPECIFICATIONS
Position desired:(*)
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Full Time
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Part Time
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Seasonal
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What days and hours are you available for work?(*)
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(Note: Work schedules are based upon the needs of the business and may be subject to change.)

Expected hourly wage:(*)
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Date available for work?(*)
Please select a date when we should contact you.

POSITION CRITERIA
Are you willing to provide care to individuals, such as:
Helping individuals who are unable to toilet themselves.(*)
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Helping individuals who are unable to feed themselves.(*)
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Are you willing to assist individuals that have behavioral challenges if:
There is a possibility that an individual may hit, kick, or bite you.(*)
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If someone exhibits inappropriate sexual behavior or uses profanity.(*)
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Are you willing to assist individuals that have physical challenges by:
Lifting and/or assisting individuals that are non ambulatory.(*)
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Learning to use mechanical devices to assist individuals.(*)
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ATTENDANCE AND PUNCTUALITY INFORMATION
Consistent attendance and punctuality are essential requirements of every job with this agency.
Is there anything which would interfere with your regular attendance and punctuality if you were offered a job with the agency?(*)
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If yes, please explain:
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EDUCATION
Grammar School
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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High School
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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College/ University
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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Vocational/ Business
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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Other School
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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ADDITIONAL EXPERIENCE OR QUALIFICATIONS
List any other experience, skills or other qualifications, which you believe should be considered in evaluating your qualifications for employment:
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Please write a brief statement (3 or 4 sentences) explaining why you want to work for Glenkirk (Please pay attention to spelling and punctuation):
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EMPLOYMENT HISTORY
(Starting with Most Recent)
Name of Employer:
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Address:
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City:
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State:
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Zip:
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Type of Business:
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Telephone Number.:
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Your Supervisor’s Name:
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Your Position Duties:
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Date of Employment:
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Date of Employment:
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Pay Rate Starting
(state hourly or salary):
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Pay Rate Ending
(state hourly or salary):
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Reason for Leaving:
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Name of Employer:
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Address:
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City:
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State:
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Zip:
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Type of Business:
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Telephone Number.:
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Your Supervisor’s Name:
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Your Position Duties:
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Date of Employment:
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Date of Employment:
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Pay Rate Starting
(state hourly or salary):
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Pay Rate Ending
(state hourly or salary):
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Reason for Leaving:
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REFERENCES
(Do Not List Relatives)
Reference 1
Name:
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Address:
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City:
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State:
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Zip:
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Occupational Title/Relationship:
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Telephone Number.:
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Length of Relationship:
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Reference 2
Name:
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Address:
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City:
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State:
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Zip:
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Occupational Title/Relationship:
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Telephone Number.:
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Length of Relationship:
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NOTIFICATION AND AGREEMENT
I certify that all answers given by me are true, accurate and complete, i understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

Questions regarding this statement should be directed to the Human Resource Department before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

Glenkirk is a Smoke-Free and Drug-Free environment. It is the policy of the Agency to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State, or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the Agency rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the Agency or me, I further understand that no representation, whether oral or written by any representative or agent of the Agency, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President/CEO, or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.
Applicant Signature(*)
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Date:(*)
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Please enter the following text:(*)
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