EmploymentApplication

APPLICATION FOR EMPLOYMENT

Pre-Employment Questionnaire – An Equal Opporunity Employer

First Name:
*

Middle Initial:


Last Name:
*

Steet Address:


City:


State:


Zip Code:

Telephone:
*

Email:
*

Position Applying For:

Special Training and/or Certification:

Date Of Birth (Required by Arizona Department of Health Services):

Are you either a US Citizen or an alien authorized to work in the United States?:
Yes  No

Have you been convicted of a felony or misdemeanor in the last five years?:
Yes  No

If Yes, Explain:

Date of Last TB test or X-Ray:

WORK EXPERIENCE

Please list last five years of work history. Caregivers must be 18 years of age and have a minimum of 3 months health related experience. Managers must be 21 years of age and have 12 months health related experience. The ADHS rules require that each employee have two professional reference checks.

Employer Name Position Held Start Date
Employer Address Employer Phone End Date
Employer Name Position Held Start Date
Employer Address Employer Phone End Date
Employer Name Position Held Start Date
Employer Address Employer Phone End Date
Employer Name Position Held Start Date
Employer Address Employer Phone End Date

CHARACTER REFERENCES

You must have two verifiable character references who are unrelated to you.

Reference Name Address Phone Number
Reference Name Address Phone Number
Reference Name Address Phone Number

All employees of an Assisted Living Center must submit to a background check by fingerprinting. You must be willing to submit to fingerprinting to assure you have not been convicted of any crime of abuse of a vulnerable adult, sexual abuse, incest, first or second degree murder, kidnapping, arson, sexual assault, sexual exploitation of a minor, contributing to the delinquency of a minor, commercial sexual exploitation of a minor, felony offenses involving distribution of marijuana or narcotic drugs, theft, robbery, a dangerous crime against children, child abuse, sexual conduct with a minor, molestation of a child, manslaughter, aggravated assault, domestic violence, fraud and fraudulent schemes, assault within the last five years or possession of a dangerous narcotic within the last five years.

To the best of my knowledge all information provided on this application is true I understand that providing false information on this application is grounds for termination.

Digital Signature:

Date:


Please type the number you see.

*

I Agree