Elder Care of North Alabama
Employment Application

Please read the following before completing application. Applicants are considered without regard to race, color, religion, sex, national origin, age or disability. All questions must be answered. You may present your resume during your interview, however, RESUMES WILL NOT BE ACCEPTED AS A SUBSTITUTE FOR APPLICATIONS.

First Name: Middle Name: Last Name: Other Names Used:

Current Address: (e.g. 123 Main St. , Anytown, AL. 35555) How Long: Primary Number:
Previous Address: (e.g. 123 Main St. , Anytown, AL. 35555) How Long: Cell Phone Number:

Email Address:

Date Of Birth:

Social Security Number:
(Are you authorized to work in the United States?
Emergency Contact: Name: Phone Number:
Alternate Phone Number: Cell Phone:
If you are an alien authorized by the Immigration and Naturalization Service to work in the United States, provide
the following: Alien Number:
or Admission Number:
(Expiration of employment authorization, if any:
Date you can start:
List the hours you are available for work each day:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

From: From: From: From: From: From: From:

To: To: To: To: To: To: To:

Are you able to work Holidays?

Education:

 

School Name

City/State

Diploma/Degree

High School

Last grade completed: 

College/Technical
School

College/Technical
School

Special qualifications and skills: (Use this space to indicate any experience, skills, licenses, or certificates, etc., which in your opinion would qualify you for the position you seek.)

Employment History:

Employer

Supervisor Title

Address (e.g. 123 Main St. , Anytown, AL. 35555)

Job Title

From (Month/Year) To (Month/Year) Starting Salary Final Salary Full Time:
Part Time:

Reason For Leaving:

May we contact this employer?
Phone Number:

Temporary:

Job Description:

 

Employer

Supervisor Title

Address (e.g. 123 Main St. , Anytown, AL. 35555)

Job Title

From (Month/Year)

To (Month/Year) Starting Salary Final Salary Full Time:

Part Time:

Reason For Leaving:

May we contact this employer?
Phone Number:

Temporary:

Job Description:

 

Employer

Supervisor Title

Address (e.g. 123 Main St. , Anytown, AL. 35555)

Job Title

From (Month/Year) To (Month/Year) Starting Salary Final Salary Full Time:
Part Time:

Reason For Leaving:

May we contact this employer?
Phone Number:

Temporary:

Job Description:

General Data:

Answer items 1 through 6. If necessary, use the "Notes" section below to provide complete information. YES/NO
1. Do you have any allergies to certain pets and/or plants? If yes, please list them in the "Notes" section.

2. Are you a smoker? (This is not used for basis of employment)
3. Are you aware of any reason which would keep you from being bonded? If yes, use "Notes" section.
4. Have you ever been convicted of an offense? Please include driving while intoxicated or driving under the influence of drugs. Use "Notes" section. (Exclude minor traffic violations.)
5. Are you licensed to operate a motor vehicle?
Driver's License Number: State: Class: Expiration:  
Identification: Endorsements:  
6. Do you have insurance on your vehicle?
Other language(s) fluently Spoken:  

Notes:

References:

List three persons other than relatives who have definite knowledge of your qualifications.

Full Name

Home or Business Address

Phone Number

Occupation

Years
Known

By pressing the "Submit Application" button below I hereby authorize and request any public or private business or other employee for whom I have worked or been employed, or with whom I have sought employment, to supply Elder Care of North Alabama with any and all records pertaining to me that have been kept in the usual course of business. The information obtained may be used by Elder Care of North Alabama in making decisions with regard to my employment.

I authorize investigation of all statements contained in this application. I certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions. I am aware that should an investigation disclose any misrepresentation, omission or falsification, my application may be rejected, or if already employed, my employment may be terminated. References and previous employer will be contacted to confirm statements unless otherwise indicated. I also understand that if offered employment by Elder Care of North Alabama, I may be required to pass a drug test and a background check as a condition of employment.

APPLICATIONS WILL NOT BE CONSIDERED UNLESS ALL QUESTIONS ARE ANSWERED.