Application for Employment

Position Applying For:

Name (Last, First, Middle):

Other names under which you have attended school or been employed:

Street Address:

City, State & Zip:

Social Security Number:

Home Phone:

Work Phone:

Other Phone:

Are you eligible to work in the United States?

☐Yes ☐No

Are you 18 years of age or older?

☐ Yes ☐ No

If NO, what is your current age?

Are you currently employed?

☐Yes ☐ No

If YES, what is your current job title & department?

Have you ever been employed by Ashby Home Health?

☐ Yes ☐No

If YES, dates of employment & reason for leaving:

Are you related to any current Ashby employee?

☐Yes ☐ No

If YES, their name & their relationship to you?

If required for position, do you have a valid driver’s license?

☐ Yes ☐ No

If YES, State of issuance, license #, and expiration date:

How did you learn about this employment opportunity? Check all that apply: ☐ Advertisement in newspaper

☐ Walk-in ☐ Online advertisement ☐ Department of Labor ☐ Referral by employee ☐Other:

 EDUCATION

Name of School

City/State

Did you graduate?

If No, # of years left to graduate

If Yes, date of Graduation

Degree received

Major

High School:

☐Yes ☐ No

GED:

☐Yes ☐ No

Other School:

☐Yes ☐ No

College:

☐Yes ☐ No

College:

☐Yes ☐ No

Other credentials/ licenses/ professional affiliations, etc., which are relevant to the job(s) for which you are applying.

 

SKILLS: Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert).

WORK EXPERIENCE: Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time, military, or volunteer commitments.         

Dates Employed (most recent position)

From:              To:

 

☐Full time ☐ Part-time

If part-time, # hrs./wk: ☐

Title:  

Starting Salary:

Organization Name and Address:  

Final Salary:  

Supervisor’s Name, Title and Phone #:  

Other Reference Name, Title and Phone #:  

Contact my current references:

☐ At any time

☐ Only if I am a finalist candidate

Primary duties:  

Reason for Leaving:  

Dates Employed (most recent position)

From:              To:

 

☐Full time ☐ Part-time

If part-time, # hrs./wk: ☐

Title:  

Starting Salary:

Organization Name and Address:  

Final Salary:  

Supervisor’s Name, Title and Phone #:  

Other Reference Name, Title and Phone #:  

Contact my current references:

☐ At any time

☐ Only if I am a finalist candidate

Primary duties:  

Reason for Leaving:  

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Ashby Home Health, LLC to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Ashby Home Health, LLC serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States, to file a State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I understand that the first 90 days of regular employment represent a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.

Ashby Home Health, LLC is an Equal Opportunity Educational Institution and EEO/Affirmative Action Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications, and without regard to race, sex, religion, national or ethnic origin, disability, age, veteran status, or sexual orientation.

Applicant Signature: ______________________________________________________        Date:  _______________________