Employment Application

Personal Data

First Name

Middle

Last Name

Address

City

State

Zip Code

Telephone

(

)

E-mail Address

Position Desired

Check One

Full Time
Part Time
Temporary

Salary Desired

*Food Service applicants must be at least 16 years old. Do you meet this requirement?

Yes
No

Date Available

(clear)

Will you be able to work overtime, if required?

Yes
No

Education

High School Name

High School City

High School State

High School Major Course or Subject

High School Years Completed

1
2
3
4

High School Type of Degree

College Name

College City

College State

College Major Course or Subject

College Years Completed

1
2
3
4

College Type of Degree

Other School Name

Other School City

Other School State

Other School Major Course or Subject

Other School Years Completed

1
2
3
4

Other School Type of Degree

Employment Record

Starting with present or most recent, list all previous employers. Include self-employment, summer and part-time jobs.

If you are now employed, may we contact your present employer?

Yes
No

Company Name

Number & Street

City & State

Zip

Supervisor's Name

Company Phone

(

)

Employment Period

From

To

Salary

Salary Start

Salary Finish

Positions & Duties

Reason for Leaving

Company Name

Number & Street

City & State

Zip

Supervisor's Name

Company Phone

(

)

Employment Period

From

To

Salary

Salary Start

Salary Finish

Positions & Duties

Reason for Leaving

Company Name

Number & Street

City & State

Zip

Supervisor's Name

Company Phone

Employment Period

From

To

Salary

Salary Start

Salary Finish

Positions & Duties

Reason for Leaving

General Information

Are you leagally authorized to work indefinitely in the United States?

Yes
No

Have you ever been convicted of or had a history of violent crime?

Yes
No

Have you ever been dismissed from employment due to abuse of clients or residents?

Yes
No

Have you ever been convicted of any felony; or a misdemeanor including but not limited to larceny, embezzlement, drawing or passing bad checks, forgery, or other similar crime involving a breach of trust or the unlawful taking or withholding of property belonging to another?(If you have, please answer 'Yes' regardless of the degree of the crime or it's technical legal name.)

Yes
No

Have you ever applied for employment with this company?

Yes
No

If yes, When

Have you ever been employed by Foulkeways?

Yes
No

From

To

How did you hear about this position?

Newspaper Ad
Walk-In
Present Employee
Other

If present employee please provide name.

If other please explain.

Have you ever been excluded or prohibited, because of fraudulent actions or default on student loans, from participating in any goverment health care benefits program including but not limited to the Medicare and Medicaid Programs?

Yes
No

Answer questions (11) and (12) only if driving a vehicle is a requirement of the job applied for.

Do you have a valid drivers license?

Yes
No

Do you own or have access to an automobile?

Yes
No

Health Center Applicant Information

Shift Preference

7-3
3-11
11-7

License Certification Number

License State

All Applicants

In addition to the above information, please indicate any other qualifications you feel you have for the position desired

I affirm that the foregoing answers are true complete and I understand that if I am employed any false statements and/or omissions herein may be considered sufficient cause for dismissal. I hereby authorize you to make such inquiries concerning the information supplied as you in your discretion deem necessary, including a criminal history check. Anyone mentioned herein is authorized to furnish you with information in connection with this application for employment.