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Today’s Date:
Birth Date
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Valid Driver's License?
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State
Please select state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
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Iowa
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Maryland
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North Carolina
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Ohio
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
#
CDL
Yes
No
Are you legally eligible for employment in the U.S.A.?
Yes
No
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?
Type of Work Desired
Full Time
Part Time
Both
Weekends
Volunteer
In What Area
Office
Aide
Van Driver
Volunteer
Maintenance
Psychologist
Nurse
Physical Therapy
Social Worker
Activities Director
Medical Records
Why do you feel you are qualified for these jobs?
How will you get to work?
Days Available
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Hours Available
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
No
Did you receive any training in the U.S. Armed Forces that is relevant to the position applied for?
Yes
No
If yes, explain
EMPLOYMENT HISTORY:
( List from most recent )
(1)
Employer & Address
Supervisor
Position Title
From
To
Describe the work you did
Salary
Reason for leaving
(2)
Employer & Address
Supervisor
Position Title
From
To
Describe the work you did
Salary
Reason for leaving
(3)
Employer & Address
Supervisor
Position Title
From
To
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
No
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