Employment Application

Our company provides equal employment opportunities to all employees and qualified applicants for employment without regard to race, color, religion, sex, national origin, age, sexual orientation, disability or status as a Vietnam-era or disabled veteran.

  • Physical, TB exam, Drug/Alcohol Tests – These elements are a condition of hire and must be passed in order to ensure that you can perform the job essentials of the position you’ve been offered.
  •  

  • Verification of Employment – The I-9 Process – Our company is a participant in the E-Verify Program that works in conjunction with Social Security and the Department of Homeland Security. As a participant in this program we will require original documentation that verifies your identity and eligibility to work in the United States. The information you complete will be transmitted to the SSA and the INS for verification of employment eligibility. Review the reverse side of this letter which shows acceptable documents from lists, “A”, “B” or “C”. Photo copies are not accepted. Associates would not be able to begin work until proof of eligibility is provided.

 

Please complete the online application below:

Required Fields are marked with *.

Date: *

First Name: * 
Middle Initial: * 
Last Name: *

Street Address: *  Apartment/Unit #:

City: *   State: *  ZIP Code: *

Primary Phone: *

Your Email: *

Date Available: *

Desired Salary: *

Position Applied For:*

For CNA/LVN, provide your certification or license number: *

Can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?*
YESNO

If you answered “yes” to any of the questions above, you will be required to provide documentation to support your answer and to verify this information in writing if an offer is made and you are hired.

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?*
YESNO

If not, what functions can’t be performed?

Have you ever worked for this company?*
YESNO

If yes, when:

Do you have any friends or relatives working for us?*
YESNO

If yes, who:

Have you previously interviewed for a job with our company?*
YESNO

If yes, when:

Have you ever been convicted of a felony or serious misdemeanor?*
YESNO

If yes, please explain:

California Residences: Do not identify marijuana-related misdemeanor or convictions that are more than two (2) years old or for which the criminal record has been expunged, sealed or eradicated by the court or for convictions for the possessions of marijuana on school grounds or possession of concentrated cannabis, and any information concerning a referral to, and participation in, any pretrial or post trial diversion program. A conviction may or may not disqualify you as an applicant. Call our HR department for any questions.

How did you hear about us?*

Do you have reliable transportation to get to work?*
YESNO

Have you ever been convicted of a moving violation within the past 5 years?*
YESNO

If yes, explain:

Do you have a valid driver's license?*
YESNO

 

EDUCATION

High School:*   
City/State:*

Did you graduate?*YESNO


College:   City/State:

From:   To:

Did you graduate? YESNO

Degree:   Date of Graduation:


Other:   City/State

From:  To:

Did you graduate? YESNO

Degree:   Date of Graduation:

 


REFERENCES

Full Name:*  Relationship:*

Company:*   Phone::*

Address:*


Full Name:*  Relationship:*

Company:*   Phone::*

Address:*


Full Name:*  Relationship:*

Company:*   Phone::*

Address:*

 

PREVIOUS EMPLOYMENT

Company:*   Phone:*

Address:*

Supervisor:*

Job Title:*

From:*   To:*

Starting Salary:*   Ending Salary:*

Reason for Leaving:*

Responsibilities:*

May we contact your previous supervisor for a reference? YESNO


Company:*   Phone:*

Address:*

Supervisor:*

Job Title:*

From:*   To:*

Starting Salary:*   Ending Salary:*

Reason for Leaving:*

Responsibilities:*

May we contact your previous supervisor for a reference? YESNO


Company:*   Phone:*

Address:*

Supervisor:*

Job Title:*

From:*   To:*

Starting Salary:*   Ending Salary:*

Reason for Leaving:*

Responsibilities:*

May we contact your previous supervisor for a reference? YESNO

 

FUN STUFF

What is the number one reason you want the job for which you are applying?*

How can you make a difference with our agency?*

What are the 3 most important things you think our agency does every day?*

Where do you see your career 3 years from now?*

 

DISCLAIMER AND SIGNATURE

Please read these: TERMS FOR EMPLOYMENT

Check here if you have read and agree to the application terms.