Careers Form

Date *

Name

Last Name *

First Name *

Middle Name *

Maiden Name *

Present Address

Number *

Street *

City *

State

Zip *

Social Security No.

How long

Telephone

If under 18, please list age

Are you authorized to work in the United States?

Yes

No

Position applied for (Be specific)

Salary Desired (Be specific)

Days/hours available to work

No Pref	Mon	Tue	Wed
Thur	Fri	Sat	Sun

How many hours can you work weekly?

Can you work nights?

Yes

No

Employment Desired

When available for work?

High School

Name of School

Location (Complete Mailing Address)

Number of Years Completed

Major & Degree

College

Name of School

Location (Complete Mailing Address)

Number of Years Completed

Major & Degree

Bus. or Trade School

Name of School

Location (Complete Mailing Address)

Number of Years Completed

Major & Degree

Professional School

Name of School

Location (Complete Mailing Address)

Number of Years Completed

Major & Degree

Are you listed on the Employee Disqualification List?

Yes

No

If yes, Explain

HAVE YOU EVER BEEN: Convicted of a crime or plead guilty or entered a plea of nolo contendere to a misdemeanor or felony charge?

Yes

No

If the answer is YES to any of the above, Please explain the following: (a)the number of conviction(s), (b) the nature of offense(s) leading to conviction/s, (c) how recently such offense/s was/were committed, (d) sentence/s imposed, (e) and type/s of rehabilitation, INCLUDE: (f) any suspended imposition of sentence, (g) any suspended execution of the sentence, (h) or any period of probation or parole.

DO YOU HAVE A DRIVER'S LICENSE

Yes

No

What is your means of transportation to work?

Driver's License Number

State of Issue

Operator

Commercial (CDL)

Chauffeur

Expiration date

Have you had any accidents during the past three years?

Yes

No

How many?

Have you had any moving violations during the past three years?

Yes

No

How many?

Office Only

Typing

Yes

No

WPM

Word Processing

Yes

No

WPM

10-Key

Yes

No

Personal Computer

Yes

No

PC

Mac

Other Skills

Please list two references other than relatives [At least one (1) reference must be employment related]

Reference 1

Name

Position

Company

Telephone

Address

Reference 2

Name

Position

Company

Telephone

Address

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

Military

Have you ever been in the Armed Forces

Yes

No

Are you now a member of the national guard?

Yes

No

Specialty

Date Entered

Discharge Date

Work Experience

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Work Experience 1

Name of Employer

Address

City

State

Zip Code

Phone Number

Name of last supervisor

Employment Dates (From)

(To)

Pay or Salary (Start)

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Work Experience 2

Name of Employer

Address

City

State

Zip Code

Phone Number

Name of last supervisor

Employment Dates (From)

(To)

Pay or Salary (Start)

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Work Experience 3

Name of Employer

Address

City

State

Zip Code

Phone Number

Name of last supervisor

Employment Dates (From)

(To)

Pay or Salary (Start)

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Work Experience 4

Name of Employer

Address

City

State

Zip Code

Phone Number

Name of last supervisor

Employment Dates (From)

(To)

Pay or Salary (Start)

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Please list any Aliases you have used:

Please list any other Social Security Numbers that you have used:

May we contact your present employer or previous employers?

Yes

No

If No, Explain

Did you complete this application yourself?

Yes

No

If not, who did?

REQUEST FOR PRE-EMPLOYMENT BACKGROUND SCREENING

Do you give consent to Aspen Home Care to conduct a pre-employment criminal record check on you which includes access to closed records check. Please check one:

Yes

No

PLEASE READ CAREFULLY. YOUR SIGNATURE BELOW CONSTITUTES AGREEMENT WITH THE FOLLOWING:
I hereby attest that all the information that I have provided herein is true and accurate and I hereby give my consent for a pre-employment criminal record check on my background which includes access to any closed records check. I understand and consent to information being obtained from the following sources: Family Care Safety Registry, Employee Disqualification List, Office of Inspector General and Department of Health and Senior Services Certified Nurse Assistant Registry or other licensing or regulatory agency (if applicable).

I understand that Aspen Home Care will not employ or continue employment of a person who is listed on the Employee Disqualification List having a finding of misconduct.

My signature below constitutes my permission for Aspen Home Care to conduct background checks listed above. I understand that failure to disclose my criminal history accurately and truthfully will constitute a class A misdemeanor.

Signature *

Date *