Job Application Click here to download the PDF version of the Application Or fill out our online job application below Date Of Application* Date Format: MM slash DD slash YYYY Position Applied ForSalary Desired*Date Available For Work* Date Format: MM slash DD slash YYYY Type Of Employment Desired* Full-Time Part-Time Temparary Volunteer Intern Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Email* Phone*Social Security Number*Contact In Emergency*Phone*Are you legally eligible for employment in this country?*YesNoProof of U.S citizenship or immigration status will be required upon employment Are you able to meet attendance requirements of this position?*YesNoHave you ever been convicted of any crime?*YesNoIf Yes, please explainHave you ever had substantiated abuse or neglect complaint ?*YesNoIf Yes, please explainEmployment HistoryList you last four employers, assignments or experience. List most recent first.Job TitleFrom* Date Format: MM slash DD slash YYYY To* Date Format: MM slash DD slash YYYY Employer*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name & Title:*Summarize work performed / job responsibilities*Ending wages / Salary*Reason for leaving*Experience 2Job TitleFrom* Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Employer*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name & Title:Summarize work performed / job responsibilities*Ending wages / Salary*Reason for leaving*Experience 3Job TitleFrom* Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Employer*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name & Title:Summarize work performed / job responsibilities*Ending wages / Salary*Reason for leaving*Experience 4Job TitleFrom* Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Employer*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name & Title:Summarize work performed / job responsibilities*Ending wages / Salary*Reason for leaving*Special Skils and qualificationsColumn 1Column 2Column 3 (i.e. foriegn languange, sign language, Red Cross certified)Educational BackgroundHigh school Name*Location of school*Year Graduated* Date Format: MM slash DD slash YYYY Major*Degree*Undergraduate studies*Location of school*Year Graduated* Date Format: MM slash DD slash YYYY Major*Degree*Graduate School*Location of school*Year Graduated* Date Format: MM slash DD slash YYYY Major*Degree*Other*Location*Year Graduated* Date Format: MM slash DD slash YYYY Major*Degree*Professional ReferencesName*Relationship*Phone*# Years Known*Name*Relationship*Phone*# Years Known*Name*Relationship*Phone*# Years Known*Name*Relationship*Phone*# Years Known*In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to investigate all refrence and to secure additional information about me, if job related, I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I also understand that a pre-employment phusical and drug screen may be required.Signature of Applicant*Release of Information (B) Read carefully before signing. I have read and do understand the statements contained herein and certify that they are true and complete without qualification. Assured Family Services has the right to terminate my employment at any time if it discovers that I have provided incomplete, untrue or misleading answers in this application or any other document or form at any time during my employment. I hereby authorize that previous employers or personal references contacted by AFS, in connection with this application fully respond to all inquiries concerning such previous employment and specifically waive prior written notice of disclosure of my personnel record information, including disciplinary reports, letters of reprimands or other disciplinary action. I also authorize educational institutions to release information relative to claimed degrees and achievements. In consideration of the acceptance of my application, I release AFS or previous employers and educational institutions of any claimed liability arising out of such response and disclosure. In the event that I am employed by this agency, I agree to comply with all its orders, rules and regulations, and acknowledge that said orders, rules and regulations do not constitute terms of employment. I hereby acknowledge that this application is for an employment of indefinite duration and understand that either AFS or I can terminate my employment and compensation, with or without cause, and with or without notice, at any time. I understand that no one other than the Executive Vice President of AFS has the authority to make any agreement (oral, written or implied) or other representations.Signature of Applicant*Date* Date Format: MM slash DD slash YYYY Release of Information (A) I understand and agree that, prior to contracting with persons who will be providing services to AFS' consumers, AFS will secure criminal history and driving record information and may require individual to complete a pre-employment physical examination using the information provided below:Name* Last Middle First Maiden name/other names used:*Sex:*Birth Date* Date Format: MM slash DD slash YYYY Race*Social Security No.*Driver's License No.*I authorize AFS to obtain the above-described information. A photocopy of this signed Authorization will carry the same effect as the original.Signature of Applicant*Date* Date Format: MM slash DD slash YYYY Resume UploadDate* Date Format: MM slash DD slash YYYY
