Untitled Document

PRE-EMPLOYMENT APPLICATION

Our company is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, national origin, veteran status, or any disability as provided in the Americans with Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered

PERSONAL

Last Name

First Name

Middle Name

Home Phone

Cell Phone

Email address:

Street Address:

City

State

ZIP

Are you a citizen of the United States or do you have the legal right to be employed in the United States? Yes No

Have you ever been convicted of any crime (excluding minor traffic violations) including driving under the influence of alcohol or drugs? Yes No

If yes, state the offense, location, date and disposition

NOTE: A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM EMPLOYMENT

Do you have the ability with or without reasonable accommodations, to work overtime or to travel if travel and/or overtime are required by the job for which you are applying? Yes No

Drivers License: State Type Currently Valid Yes No

EMPLOYMENT DESIRED

Are you seeking Full-Time Part-Time Temporary or Seasonal Employment

Position applied for Desired Salary (per hour) Date available to start (mm/dd/yyyy)

Have you ever applied for a position with AdvaCare?

Yes No

Have you ever worked for AdvaCare?

Yes No

If yes, state when or where you applied and/or worked

How did you learn of our company and/or position?

Are there any days or hours you would be unwilling or unable to work? Yes No

If yes, please specify those dates or hours you would be unwilling or unable to work

WORK HISTORY

List name of employers in consecutive order, with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references

PLEASE GIVE MONTH AND YEAR

DO NOT REFERENCE YOUR RESUME

Name of Employer (Address, City, State, Zip)	Name & Title of Last Supervisor
	Telephone
Dates Employed From: Month Year To: Month Year Title
Pay (per hour): Starting $ Ending $
Reason for leaving?

Name of Employer (Address, City, State, Zip)	Name & Title of Last Supervisor
	Telephone
Dates Employed From: Month Year To: Month Year Title
Pay (per hour): Starting $ Ending $
Reason for leaving?

Name of Employer (Address, City, State, Zip)	Name & Title of Last Supervisor
	Telephone
Dates Employed From: Month Year To: Month Year Title
Pay (per hour): Starting $ Ending $
Reason for leaving?

Name of Employer (Address, City, State, Zip)	Name & Title of Last Supervisor
	Telephone
Dates Employed From: Month Year To: Month Year Title
Pay (per hour): Starting $ Ending $
Reason for leaving?

EDUCATION

High School Name (City, State)	Graduate? Yes No
Area of Study/Degree and/or Certification Received

Collegel Name (City, State)	Graduate? Yes No
Area of Study/Degree and/or Certification Received

Other School Name (City, State)	Graduate? Yes No
Area of Study/Degree and/or Certification Received

Are you planning to pursue further studies? Yes No

If yes when, where and what courses

List and describe any other schooling or specialized training

MILITARY

Have you ever served in the military? Yes No

Service Branch Date Entered (mm/dd/yyyy) Date Separated (mm/dd/yyyy) Final Rank

CAPABILITY/RELIABILITY

Would you be willing and able to perform all of the tasks required by the job you are applying for? Yes No

If no, please explain which tasks

Have you ever filed any type of fraudulent claim(s) against any of your past/present employers Yes No

If yes, please explain

Have you ever been disciplined for violating company safety rules or regulations? Yes No

If yes, please explain

How many days of work (or school) have you missed in the last two years?

How many times have you been late for work (or school) in the last two years?

Would you be willing and able to report to work on time every day on a regular and consistent basis? Yes No

If no, please explain

SUPPLEMENTAL EMPLOYMENT INFORMATION

If you worked under an alias at any of your previous positions, please provide them in the space provided (for reference purposes)

Name	Name
Company	Company

Are you presently employed? Yes No

If yes, may we contact your present employer? Yes No

Have you ever been fired or asked to resign from a position? Yes No

If yes, please explain

Have you ever been disciplined or received verbal/written warnings for violating company policy Yes No

If yes, please explain

SPECIAL SKILLS

Do you type? Yes No

WPM or KPH

Have you used a computer in the workplace? Yes No

If yes, please list any software/programs you have used

Are you Bi-Lingual? Yes No

If yes, please list languages you speak fluently

Use the space below to describe why you are interested in working for our company and to list those skills and abilities which you feel particularly qualify you for a position with us.

REFERENCES

Give at least three professional references (no relatives)

Name	Phone	Occupation
Address

Name	Phone	Occupation
Address

Name	Phone	Occupation
Address

AFFIDAVIT

I certify that my answers to the preceding questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree that if I am employed I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such test when asked will be grounds for my immediate termination. I further understand that nobody in the Company is authorized to enter in to any written or verbal contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my employment is “at-will” and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without prior notice.