HealthPoint Family Care - Jobs - Employment Application

All fields labeled with an asterisk (*) are required.

Personal Information
*Full Name:
*Social Security No.:
*Present Address:
*City:
*State:
*Zip:
*Phone:
Email:
*Are you 18 years or older?	Yes No
*Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?	Yes No

Employment Desired
Position:
Date You Can Start:
Salary Desired:
Are you employed now?	Yes No
If so may we inquire of your present empoyer?	Yes No
Have you ever applied to this company before?	Yes No If yes, where and when?
Have you ever worked for this company before?	Yes No If yes, where and when?
Reason for leaving:
Who referred you to this company?	Employment Agency Newspaper Advertisement Other State Employment Office College Placement Service Walked in Friend

Education
Grammar School:	Name:
	Location:
	Dates attended:	to
High School:	Name:
	Location:
	Dates attended:	to
		Did you graduate? Yes No
College:	Name:
	Location:
	Dates attended:	to
		Did you graduate? Yes No
Trade, Business or Correspondence School	Name:
	Location:
	Dates attended:	to
		Did you graduate? Yes No

General
Subjects of Special Study or Research Work:
Special Training:
Special Skills:

Former Employers (List below last three employers, starting with last one first.)
1.	Company Name:
	Location:
	Employed from:	to
	Weekly Starting Salary:	$
	Weekly Final Salary:	$
	Job Title:
	May we contact your supervisor?	Yes No
	Name and Title of Supervisor:
	Phone Number:
	Description of work:
	Reason for leaving:
2.	Company Name:
	Location:
	Employed from:	to
	Weekly Starting Salary:	$
	Weekly Final Salary:	$
	Job Title:
	May we contact your supervisor?	Yes No
	Name and Title of Supervisor:
	Phone Number:
	Description of work:
	Reason for leaving:
3.	Company Name:
	Location:
	Employed from:	to
	Weekly Starting Salary:	$
	Weekly Final Salary:	$
	Job Title:
	May we contact your supervisor?	Yes No
	Name and Title of Supervisor:
	Phone Number:
	Description of work:
	Reason for leaving:

References (Give below the names of three persons not related to you, whom you have known at least one year.)
1.	Name:
	Phone Number:
	Business:
	Years Acquainted:
	Relationship:
2.	Name:
	Phone Number:
	Business:
	Years Acquainted:
	Relationship:
3.	Name:
	Phone Number:
	Business:
	Years Acquainted:
	Relationship:

Service Record
Branch of Service:
Discharge Date Rank:
Present Membership in National Guard or Reserves:
Date Obligation Ends:

By submitting this form, I certify that all information submitted by me on this application is true and correct, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and condition of my employment may be changed, with or without cause and with or without notice. At any time by the company, I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

All information in this employment application is sent across a secure line.

All fields labeled with an asterisk (*) are required.