APPLICATION FOR EMPLOYMENT
Please print or type all information except signature.

Non-Discrimination Policy: Agape Home Care Services is committed to the principle of equal opportunity in employment.  We do not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.

GENERAL INFORMATION

Date                          

Position(s) Applied For  (1)                    ________________________________________

                                       (2)                                         

Referral Source    ☐ Friend   ☐ Relative   ☐ Employment Agency     ☐ Agape website    

                             ☐ Internet Search                 ☐ Walk-in              ☐Other____________________

Name                                                                                              

        Last                         First                         Middle                         

Address                                                                                           

                        Number                        Street                City        State        Zip

Home Telephone (     )                         

Cell Phone (      )                          

E-mail address                               

Social Security number                              

If under 18, can you provide a work permit?  ☐ Yes     ☐ No     

Have you ever filed an application here before?   ☐ Yes     ☐ No      If yes, give date                         

Have you ever been employed here before?   ☐ Yes      ☐No           If yes, give date                         

Are you currently employed?   ☐ Yes     ☐ No

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

If hired, are you legally eligible for employment in the United States?    ☐ Yes     ☐ No    
(Proof of legal work status will be required upon employment)

Employment desired:   ☐ Full-Time      ☐ Part-Time     ☐ Per Diem     ☐ Temporary    

When are you available to start?                    

Shifts available to work   ☐ Days     ☐ Evenings ☐ Nights   ☐ Weekends

Can you travel locally if a job requires it?  ☐ Yes     ☐ No

EDUCATION

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION
(Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School

College

Graduate School

Bus. or Trade School

Professional School

Special Honors                                                                                           

COMPUTER SKILLS (Only for positions which require computer skills)

Check off those computer skills with which you are proficient (any version).

☐ PC User

☐ Macintosh User

☐  Windows

☐ Microsoft Word

☐ Microsoft Excel

☐ Microsoft Publisher

☐  Microsoft Powerpoint

☐ Other.  Please list                                                                                 __

DRIVER’S LICENSE (Only for positions which require driving)

Do you have a driver’s license?        ☐ Yes        ☐ No

Driver’s license
number                                          State of issue                   ☐ Operator     ☐ Commercial (CDL)                                          ☐Chauffeur

Expiration date                                  

OTHER SPECIAL SKILLS

Please list other special skills you may have, e.g., fluency in other languages, licenses, special training required for the position for which you are applying, etc.

WORK EXPERIENCE

Please list your work experience beginning with your most recent job. If you were self-employed, give firm name.  Attach additional sheets if necessary.  Exclude organization names which indicate race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability.

Most Recent Employer

Dates Employed

From:                     

To:                     

Final pay rate:                      

Work Performed

Address

Supervisor

Job Title

Reason for Leaving

Employer

Dates Employed

From:                     

To:                     

Final pay rate:                      

Work Performed

Address

Supervisor

Job Title

Reason for Leaving

Employer

Dates Employed

From:                     

To:                          

Final pay rate:                      

Work Performed

Address

Supervisor

Job Title

Reason for Leaving

Employer

Dates Employed

From:                          

To:                               

Final pay rate:                      

Work Performed

Address

Supervisor

Job Title

Reason for Leaving

REFERENCES
Please list two references other than relatives.  Prior employers preferred.

Name                                         

Name                                              

Position                                        

Position                                        

Company                                                 

Company                                        

Address                                        

Address                                        

Telephone (     )                              

Telephone (     )                              

WAIVERS AND DISCLOSURES

Please read each section carefully and sign where indicated.

AT-WILL EMPLOYMENT

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization.  I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer.  I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization.

CERTIFICATION OF TRUTH AND ACCURACY

I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.

NOTIFICATION AND AUTHORIZATION TO REQUIRE A TUBERCULOSIS SCREENING

I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the essential functions of the job.  I further understand as a Health care employee I will be required to undergo a two-step Tuberculin skin testing by a PPD test or chest x-ray.

NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

I understand that I may be subject to a background check, and hereby authorize Department of Social and Health Services (DSHS), to investigate my background to determine any and all information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information.

Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records and criminal records through an investigative or credit agency or bureau of your choice.  I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required.  

I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired.

PLEASE SIGN HERE:                                                     Date                                

Non-Discrimination Policy: Agape Home Care Services is committed to the principle of equal opportunity in education and employment.  The University does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.

Non-Discrimination Policy: Agape Home Care Services is committed to the principle of equal opportunity in education and employment.  Agape does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.

Solely to help us comply with government record keeping, reporting, and other legal requirements, please fill out the Application Data Record.  We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

DATE:         

Positions(s) applied for:  

Referral Source    ☐ Friend    ☐ Relative    ☐ Employment Agency   ☐  ☐ Walk-in            

                             ☐ Internet Search ______________        ☐ Agape’s website           ☐ Other__________

                                                                   (Please list website)

Name                                                                                          

        Last                         First                         Middle                         Maiden

Address                                                                                      

                        Number                        Street                City        State        Zip

Telephone (     )                        

Affirmative Action Survey

Check one

Check one

Check any that apply

Government agencies require periodic reports on the sex, ethnicity, disability, and veteran status of applicants. Submission of information about a disability is voluntary.  This data is for analysis and affirmative action only.

☐ Male

☐ Female

☐ White

☐ Black

☐ Hispanic

☐ American Indian/ Alaskan Native

☐ Asian/Pacific Islander

☐ Disabled

☐ Vietnam Era Veteran

☐ Disabled Veteran

Special Employment Notice to disabled veterans, Vietnam Era veterans, and individuals with a physical or mental disability.

Government contractors are subject to Section 402 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled individuals.

If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information.  The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner.  This information will be treated as confidential.  Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment.

If you wish to be identified, please sign below:

☐ Disabled individual     ☐ Disabled Veteran      ☐ Vietnam Era Veteran

Signature:                                                         Date