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Employment Application
Name
Address
Home phone
Cell Phone
Email
Position Sought
Social Security Number
Salary Requirement
Available start date
Type of employment desired:
Full-time
Part time
Temporary
Seasonal
Have you ever worked for The Hendricks House Group before?
Yes
No
Have you ever applied to The Hendricks House Group before?
Yes
No
If yes, please explain:
Do you have any friends, relatives, and/or acquaintances working for The Hendricks House Group?
Yes
No
If yes, please list name and relationship
Please list your areas of highest proficiency, special skills, or other items that may contribute to your abilities in performing the position for which you are applying
Do you speak, write, or understand any foreign language?
Yes
No
If yes, which language(s) and how fluent of a speaker you cosider yourself to be
High School: Name & Location
Date of Graduation
Degree
Major/Subjects of study
College or University: Name & Location
Date of Graduate
Degree
Major/Subjects of study
Specialized Training, Trade School, etc: Name & Location
Date of Graduate
Degree
Major/Subjects of study
Other Education: Name & Location
Date of Graduate
Degree
Major/Subjects of study
Licenses
Other credentials
1. Previous Employer Name
Dates Employed
Position Title
Supervisor Name
Salary
Position Responsibilities
Reason for Leaving
2. Previous Employer Name
Dates Employed
Position Title
Supervisor
Salary
Position Responsibilities
Reason for Leaving
3. Previous Employer Name
Dates Employed
Position Title
Supervisor
Salary
Position Responsibilities
Reason for Leaving
If you are currently employed, may we contact your present employer?
Yes
No
If yes, please list contact person and phone number
If hired, would you be able to present evidence of your U.S citizenship or proof of your legal right to work in the United States?
Yes
No
If hired, are you willing to submit to and pass a controlled substance test?
Yes
No
If hired, are you willing to submit to a background check using fingerprints?
Yes
No
Do you smoke?
Yes
No
Are you able to perform the functions of the position for which you are applying, either with or without reasonable accommodations?
Yes
No
If no, describe the functions you cannot perform:
Are there any other areas of the job description that you cannot meet?
Yes
No
If yes, what are those areas?
Please read and initial each paragraph and then sign below
I certify that i have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that any omission (including any misstatement) of material fact on this application or any document used to secure employment can be grounds for rejection of application or, if I am employed by The Hendricks House Group, terms for my immediate termination from The Hendricks House Group.
I understand that I am employed, my employment is not definite and can be terminated at any time either with or without prior notice and by either me or The Hendricks House Group (The Hendricks House Group is an AT WILL EMPLOYER)
I permit The Hendricks House Group to examine my references, record of employment, education record, and any other information I have provided. I authorize the references (both professional and personal) I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release The Hendricks House Group, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of or in any way related to such examination or revelation.
Signature
Date
Send
