Job Application

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Date Of Application*
MM slash DD slash YYYY
Position Applied For
Salary Desired*
Date Available For Work*
MM slash DD slash YYYY
Type Of Employment Desired*
- Full-Time
- Part-Time
- Temporary
- Volunteer
- Intern
Name*
First Last
Address*
Street Address * Address Line 2 * City * State * ZIP Code *
Applicant Email*
Phone*
Social Security Number*
Emergency Contact*
Emergency Contact Phone Number*
Are you legally eligible for employment in this country?*
- Yes
- No
Proof of U.S citizenship or immigration status will be required upon employment
Are you able to meet attendance requirements of this position?*
- Yes
- No
Have you ever been convicted of any crime?*
- Yes
- No
If Yes, please explain
Have you ever had substantiated abuse or neglect complaint ?*
- Yes
- No
If Yes, please explain
Employment History
List you up to four previous employers, assignments, or experience. List most recent first.
Experience 1
Job Title
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Employer*
Address*
Street Address * Address Line 2 * City * State * ZIP Code *
Supervisor Name & Title:*
Summarize work performed / job responsibilities*
Ending wages / Salary*
Reason for leaving*
Experience 2
Job Title
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Supervisor Name & Title:*
Summarize work performed / job responsibilities*
Ending wages / Salary*
Reason for leaving*
Experience 3
Job Title
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Employer
Address
Street Address Address Line 2 City State ZIP Code
Supervisor Name & Title:
Summarize work performed / job responsibilities
Ending wages / Salary
Reason for leaving
Experience 4
Job Title
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Employer
Address
Street Address Address Line 2 City State ZIP Code
Supervisor Name & Title:
Summarize work performed / job responsibilities
Ending wages / Salary
Reason for leaving

Special Skils and qualifications

Column 1	Column 2	Column 3

(i.e. foriegn languange, sign language, Red Cross certified)

Educational Background
High School Name*
Location of school*
Year Graduated*
MM slash DD slash YYYY
Degree*
Undergraduate Studies
Location of school
Year Graduated
MM slash DD slash YYYY
Major
Degree
Graduate School
Location of school
Year Graduated
MM slash DD slash YYYY
Major
Degree
Other
Location
Year Graduated
MM slash DD slash YYYY
Major
Degree
Professional References
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*
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 (If Applicable)
Sex:*
Birth Date*
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*
MM slash DD slash YYYY
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Date*
MM slash DD slash YYYY
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Job Application

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Employment History

Experience 1

Experience 2

Experience 3

Experience 4

Educational Background

Professional References

Release of Information (B)

Release of Information (A)