Please fill out this application: Fields marked with an * are required Location: * Virginia Georgia Availability: check all that you could work Availability: check all that you could work Mon Tues Wed Thurs Fri Sat Sun Day hours Evening hours (5-9P) Nights (9P-12MN) Overnights Live in Date of Application: Date Available for Employment: Position Applying For: Type of Employment Desired: Per Diem Part Time Full Time First Name Middle Initial Last Name Address City US State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip Home Phone Cell Phone Work Phone Email Social Security Number Languages written/spoken Date of Birth Have you ever been employed here before? No Yes If yes, when? Are you legally eligible for employment in the US? No Yes Do you have a social security card? No Yes If not legal citizen: Do you have a green card? No Yes Has your visa expired? No Yes How did you hear about us? Newspaper Ad - Newspaper? Internet - Which Site? Current Employee - Who? Other EMERGENCY CONTACT INFORMATION - Name: Relationship Home Phone Cell Phone Work Phone Nacolby’s House INC an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status. Work History Employment History - Please begin with your most recent or current place of employment. Place of Employment: Address: Position Supervisor: Reason for Leaving: Date Previous Job Started: Date Previous Job Ended: Phone Number: Salary: Final Salary: Divider Position Address: Place of Employment: Supervisor: Reason for Leaving: Date Previous Job Started: Date Previous Job Ended: Phone Number: Salary: Final Salary: Divider Copy Education Education High School: Other: College: Other: Divider Copy Copy Military Service Military Service Branch of Service: Highest Rank Achieved: Dates of Service: Currently in a Reserve Unit? Yes No Special Schooling and/or Duties: Divider Copy Copy Copy Licenses and Certifications Licenses and Certifications License or Certification, ID Number, Expiration Date, State License or Certification, ID Number, Expiration Date, State Copy License or Certification, ID Number, Expiration Date, State Copy Copy Divider Copy Copy Copy Copy Have you ever been convicted of violating any law? (Please omit minor traffic violations.) Yes No IF YES, PLEASE LIST CONVICTION(S), DATE(S) AND LOCATION(S). THE PRESENCE OF A CRIMINAL RECORD IS NOT AN AUTOMATIC REJECTION OF YOUR APPLICATION. CERTAIN TYPES OF CONVICTIONS WILL ELIMINATE YOU FROM SERVICING VULNERABLE ELDERS IN THEIR HOMES. I ATTEST THAT THE ABOVE REFERENCED INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I FURTHER GIVE THE AGENCY PERMISSION TO CALL ANY OF MY CITED PREVIOUS EMPLOYERS OR REFERENCE CANDIDATE FOR INFORMATION REGARDING MY CHARACTER, EMPLOYMENT HISTORY OR WORK ETHICS. If you are a human seeing this field, please leave it empty.
