Hope Harbor Employment Application APPLICANT INFORMATION Today's Date * MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date Available * MM DD YYYY Desired Salary * $ Position Applied For * Direct Care Staff - Evening Direct Care Staff - Day If hired, can you provide proof of your employment eligibility in the U.S.? * Yes No Have you ever worked for this company? * Yes No If so, when? Have you ever been convicted of a felony? * Yes No If yes, explain. EDUCATION High School Name and Address Did you graduate? * Yes No Degree College Name and Address Did you graduate? * Yes No Degree Other PREVIOUS EMPLOYMENT Please list your three most recent employments. Company #1 Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisor First Name Last Name Job Title Starting Salary $ Ending Salary $ Responsibilities Start Date MM DD YYYY End Date MM DD YYYY Reason for Leaving May we contact your previous supervisor for a reference? Yes No Company #2 Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisor First Name Last Name Job Title Starting Salary $ Ending Salary $ Responsibilities Start Date MM DD YYYY End Date MM DD YYYY Reason for Leaving May we contact your previous supervisor for a reference? * Yes No Company #3 Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisor First Name Last Name Job Title Starting Salary $ Ending Salary $ Responsibilities Start Date MM DD YYYY End Date MM DD YYYY Reason for Leaving May we contact your previous supervisor for a reference? Yes No REFERENCES Please list three references whom are not related to you and are not previous employers. Reference Name #1 * First Name Last Name Relationship * Company * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Reference Name #2 * First Name Last Name Relationship * Company * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Reference Name #3 * First Name Last Name Relationship * Company * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country OTHER INFORMATION Please list any information you consider helpful in considering you for this position: * DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I authorize the references listed above to provide any and all information concerning my current or previous employment. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information. Signature * First Name Last Name Date * MM DD YYYY Thank you!
