| Application for Employment |
| Personal Information |
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First Name:
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Last Name:
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Middle Name:
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Street Address:
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City:
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State:
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Zip:
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Home Phone:
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EX: 123-456-7890 |
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Work Phone:
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EX: 123-456-7890 |
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Email Address:
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Are you authorized to work in the United States? (Verification will be required upon hire.)
Yes No |
Are you over 18 years of age? (Verification will be required upon hire.)
Yes No |
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Job Interest
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| Position desired: |
full time part time days
evenings weekends temporary/seasonal |
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Starting Date:
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Pay per hour expected:
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Average # of hours per week desired:
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How were you referred to us?
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Education - Licensure - Certification
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Graduate School
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Graduate school name:
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Graduate school address:
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Course of study:
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Number of years completed:
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Did you graduate?
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yes no |
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Name of degree, certificate or diploma:
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College
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College name:
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College address:
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Course of study:
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Number of years completed:
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Did you graduate?
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yes no |
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Name of degree, certificate or diploma:
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School name:
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School address:
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Course of study:
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Number of years completed:
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Did you graduate?
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yes no |
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Name of degree, certificate or diploma:
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School name:
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School address:
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Course of study:
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Number of years completed:
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Did you graduate?
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yes no |
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Name of degree, certificate or diploma:
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| License, Registration, Certification |
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1. Type:
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License #:
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Expiration date:
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State:
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2. Type:
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Certification#:
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Expiration date:
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State:
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Other specialized training (i.e. technical training, etc.)
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Please describe:
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Office skills (i.e. types of office machines and software you can operate)
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Please describe:
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References
(List three prior employees or supervisors who can comment on your abilities.) |
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Reference 1
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Name:
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Company Name:
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Telephone:
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EX: 123-456-7890 |
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Title/Position:
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How long have you worked together?
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| Reference 2 |
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Name:
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Company Name:
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Telephone:
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EX: 123-456-7890 |
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Title/Position:
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How long have you worked together?
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| Reference 3 |
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Name:
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Company Name:
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Telephone:
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EX: 123-456-7890 |
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Title/Position:
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How long have you worked together?
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| Employment History |
| Employer 1 |
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Employer
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May we contact this employer as a reference?
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yes no |
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Telephone:
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EX: 123-456-7890 |
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Address:
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Dates of employment (mm/yy):
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Name of Supervisor:
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Start:
End: |
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Describe your job title and responsibilities:
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Reason for leaving:
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Employer 2
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Employer
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May we contact this employer as a reference?
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yes no |
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Telephone:
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EX: 123-456-7890 |
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Address:
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Dates of employment (mm/yy):
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Name of Supervisor:
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Start:
End: |
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Describe your job title and responsibilities:
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Reason for leaving:
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| Employer 3 |
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Employer
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May we contact this employer as a reference?
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yes no |
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Telephone:
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EX: 123-456-7890 |
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Address:
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Dates of employment (mm/yy):
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Name of Supervisor:
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Start:
End: |
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Describe your job title and responsibilities:
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Reason for leaving:
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| Other Information |
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Have you ever been convicted of a felony?
yes no
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If yes, give details:
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| In answering the following questions, do not included a first conviction for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace. |
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Have you ever been convicted of a misdemeanor within the past five years?
yes no
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If yes, give details:
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Have you ever been convicted of a misdemeanor five or more years ago?
yes no |
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If yes, give details:
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PLEASE READ CAREFULLY
I certify that the information provided by me in this application is correct and complete to the best of my knowledge. I understand that any false information or omission of fact may disqualify me for employment and may be cause of dismissal at a later date. I understand that employment is conditional upon satisfactory replies from my references.
I understand and agree that any offer of employment is contingent upon satisfactory completion of SCS pre-employment investigation which includes but is not limited to health assessment, criminal history check (CORI), educational and work verification, reference checks, consumer report and any investigating required by state laws.
I understand that acceptance of an offer of employment does not create a contractual obligation and that either party may terminate the employment relationship, at will, at any time and for any reason or no reason.
Standards Care Staffing Inc, is an Equal Opportunity Employer and does not unlawfully discriminate in employment decisions because of race, religion, color, national origin, age, disability, sex, or veteran.
I have read, understood, and agree with the before mentioned statements.
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