Employment Application - Guardian Angel Staffing

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Name

First

Last

Present Address

Phone Number

If you cannot be reached at above phone number, where may we contact you?

Name of Person & Phone Number

Where did you hear of this job opening?

Referral
Internet
Other

Will you accept Employment of:

Full-Time
Part-Time
Temporary

Date Available

If Under 18 years of age, do you have a work permit?

Employment Desired - 1st Choice

Shift/Salary

Employment Desired - 2nd Choice

/Shift/Salary

Education/Training - Highschool

Name and Address of School/Courses

Did you graduate?

Diploma, Degree or Certificate Received

Education/Training - College

Name and Address of School/Courses

Did you graduate?

Diploma, Degree or Certificate Received

Education/Training - Lab/X-Ray Training

Name and Address of School/Courses

Did you graduate?

Diploma, Degree or Certificate Received

Extracurricular Activities While In School

Area of Specialization of Major Interest

Professional Organization Membership, Honors Received, Volunteer or Community Service or Other Qualifications Related To Position For Which You Are Applying

Professional Licenses and/or Certifications

Type/Organization or State Issued

Date Issued and Number

Professional Licenses and/or Certifications

Type/Organization or State Issued

Date Issued and Number

Professional Licenses and/or Certifications

Type/Organization or State Issued

Date Issued and Number

Military Record

Military Branch/Entry Rank/Separation Rank & Date

Military Occupational Specialty

Military Specialized Training

List Service Awards, Commendations

Employment History - List current (most recent) employer first and all others in reverse chronological order

Company Name & Address

Position & Job Description

Starting Salary - Ending Salary

Supervisors Name/Title & Phone Number

May We Contact For Reference

Employment History

Company Name & Address

Position & Job Description

Starting Salary - Ending Salary

Supervisors Name/Title & Phone Number

May We Contact For Reference

Employment History

Company Name & Address

Position & Job Description

Starting Salary - Ending Salary

Supervisors Name/Title & Phone Number

May We Contact For Reference

Employment History

Company Name & Address

Position & Job Description

Starting Salary - Ending Salary

Supervisors Name/Title & Phone Number

May We Contact For Reference

Have you ever been convicted of a crime?

If yes, for what, when and where?

Conviction of a criminal offense will not necessarily preclude your employment.

Use this space to give us further information which may assist us in placing you.

Reference #1-List three references who are not relatives or former employers

Name & Relationship/Title Company Name & Address/Phone Number

References #2

Name & Relationship/Title Company Name & Address/Phone Number

References #3

Name & Relationship/Title Company Name & Address/Phone Number

Primary Position Desired

Will you accept another position?

If yes, what position?

Are you available to work weekends?

Are you available to work rotating shifts?

Are you available to work on call?

Availability Information - Sunday

From - To

Monday

From - To

Tuesday

From - To

Wednesday

From - To

Thursday

From - To

Friday

From - To

Saturday

From - To

Please upload & submit the following documents and return via email:

Please upload a copy of your Photo ID, Liability Insurance, Direct Care/CNA Certifications, CPR Certifications & PPD

I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution. If availability changes, it is my responsibility to notify your department head or the administrator. Such changes will be effective, then, for any future employment.

Name/Date

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam, Veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform. I understand my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification For (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

Name/Date