Job Application Form

* = Required Information

Applicant Information

Position Applied for:

Full Time

Part Time

Date:

Last Name: *

First Name: *

Middle Name:

SS#:

DOB:

Street Address:

Apartment/Unit #:

City:

State:

Zip:

Phone: *

E-mail Address: *

Are you a citizen of the United States?:

Yes

If no, are you authorized to work in the U.S.?:

Yes

Have you ever worked for this company?:

Yes

If so, when?:

Have you ever been convicted of a felony?:

Yes

If yes, explain

Education

High School:

Address:

From:

To:

Did you graduate?:

Yes

Degree:

College:

Address:

From:

To:

Did you graduate?:

Yes

Degree:

Other:

Address:

From:

To:

Did you graduate?:

Yes

Degree:

Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?:

YES

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?:

YES

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?:

YES

Emergency Contact

Name of Contact:

Phone Number:

Relationship to Contact:

Disclaimer and Signature

I understand and agree that: The information supplied, was submitted by myself, and all information is true and correct, to the best of my knowledge. I understand that false or misleading information given in my application and/or interview(s) will be considered as cause for possible dismissal and/or discharge. I also understand that I am to abide by all rules and regulations of the company.

The company has my authorization to thoroughly investigate my work and personal history. I understand that the information supplied by me, regarding my: Employment History, Education (including an authorization to release transcripts), Credit History, Criminal History, Medical and Professional Licensing, Motor Vehicle Record(s), Residence History, and References, will be utilized as part of the processing procedures.

A background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information concerning my character, general reputation, personal characteristics, and mode of living. I will hold no person liable for giving or receiving information in this investigation.

I hereby authorize SentryLink LLC, an agent of L.A. Metropolitan Home Health to make a thorough check of my past Employment, Education, and activities.

I release from liability all persons, companies, and corporations supplying that information.

I release and indemnify L.A. Metropolitan Home Health and SentryLink LLC against any liability that might result from making such background checks. A copy of this form is as valid as the original.

Attach Resume

Signature:

Date:

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