Careers/Employment Form

* = Required Information

Today’s Date:

Birth Date *

SS#

Name *

Street Address *

City *

State

Zip

Email *

Home Phone

Cell Phone

Emergency Phone *

Valid Driver's License?

Yes

State

CDL

Yes

Are you legally eligible for employment in the U.S.A.?

Yes

If so, verification required

Are you still attending high school?

Do you have required working papers?
(Needed on or before the first day of work)

Did we ever employ you?

If so, When?

Have you ever worked for a healthcare company?

Where?

Have you ever worked in an Adult Day Care?

Where?

How did you hear about the position you are applying/volunteering for?

Why do you feel you are qualified for these jobs?

How will you get to work?

If there is a day or time when you are definitely not available, please indicate here

Have you ever been convicted of a crime?

if so, describe in full

EDUCATION
SPECIAL SKILLS AND QUALIFICATIONS

Elementary

Name & Address

Yrs. Completed

Did you Graduate?

Degree/Field

High School

Name & Address

Yrs. Completed

Did you Graduate?

Degree/Field

College

Name & Address

Yrs. Completed

Did you Graduate?

Degree/Field

Other

Name & Address

Yrs. Completed

Did you Graduate?

Degree/Field

Special accomplishments & Acquired skills

MILITARY SERVICE RECORD

Were you in the U.S. Armed Forces?

Yes

Did you receive any training in the U.S. Armed Forces that is relevant to the position applied for?

Yes

If yes, explain

EMPLOYMENT HISTORY:
( List from most recent )

(1)

Employer & Address

Supervisor

Position Title

From

Describe the work you did

Salary

Reason for leaving

(2)

Employer & Address

Supervisor

Position Title

From

Describe the work you did

Salary

Reason for leaving

(3)

Employer & Address

Supervisor

Position Title

From

Describe the work you did

Salary

Reason for leaving

I HEREBY GIVE PERMISSION TO CONTACT THE EMPLOYERS LISTED ABOVE CONCERNING MY PRIOR WORK EXPERIENCE. *

Yes

Please Read:
The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I also understand that this application is not intended to be a contract of employment. Furthermore, this application does not obligate the employer in any way if the employer decides to employ me. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative agencies, credit agencies, or bureaus of your choice. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of any investigative report that is made.

Personal References: (Not former employers or relatives) 2 or 3

Name & Occupation

Address

Phone Number

Sign *

Date *

*TB screening is required for all volunteers and employees at Raspberry Hill ADC.
*We have the TB form required.

Mail or (Scan, then Email to):

Raspberry Hill Adult Daytime Center
2617 Elk Valley Road
Forest, VA. 24551
eddieandtara@raspberryhilladc.com