Name

Last Name

First Name

Initial

Current Address

Street

City

State

AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY -- AB BC MB NB NF NS NT ON PE SK YT

Zip

Permanent Address

Street

City

State

AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY -- AB BC MB NB NF NS NT ON PE SK YT

Zip

Phone Number .......................................

Are you 18 years or older ..............

Choose Yes No

Are you either a United States Citizen or authorized to work in the United States ..........................................................

Choose Yes No

Employment Position Desired ................

Date You Can Start .................................

Salary Desired

Are You Currently Employed .................

Choose Yes No

May We Contact Your Current Employer

Choose Yes No

Have You Applied With Erwine Home Health and Hospice Inc. in the Past ....................................................................

Choose Yes No

If so where

When

Referred By ............................................

HAVE YOU EVER BEEN CONVICTED OF A CRIME? (Do not include convictions for which the records were sealed or expunged.
A conviction does not automatically disqualify an applicant from a particular position)

Choose Yes No

IF YES, LIST THE NATURE OF OFFENSE(S), DATES OF CONVICTION AND DATES OF INCARCERATION.

HAVE YOU EVER BEEN NAMED ON A CENTRAL CHILD ABUSE REGISTRY AS BEING A
PERPETRATOR OF FOUNDED OR INDICATED CHILD ABUSE?

Choose Yes No

Education

School Name and Location

Years Attended

Did You Graduate

Subjects Studied

Grammar

Choose 0 1 2 3 4 5 6 7 8 9

Choose Yes No

High School

Choose 0 1 2 3 4 5 6 7 8 9

Choose Yes No

College

Choose 0 1 2 3 4 5 6 7 8 9

Choose Yes No

Other

Choose 0 1 2 3 4 5 6 7 8 9

Choose Yes No N/A

*The Age Discrimination Employment Act of 1987 prohibits discrimination on the basis of age
with respect to anyone that is at least 40 years of age.

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK:

SPECIAL SKILLS

ACTIVITIES: (CIVIC, ATHLETIC, ETC.)

*PLEASE EXCLUDE ORGANIZATIONS THAT INCLUDE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.

U.S. MILITARY/NAVAL SERVICES:

Rank

ARE YOU PRESENTLY A MEMBER OF THE NATIONAL GUARD OR RESERVES ........................................

Choose Yes No

FORMER EMPLOYERS (STARTING WITH PRESENT OR MOST RECENT):

Date Start - End

Employer Name & Address

Salary

Position

Reason for Leaving

Which of these Jobs did You enjoy best and Why

REFERENCES: (GIVE THE NAMES OF (3) PERSONS, NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.)

Name

Address

Phone

Business

Years Acquainted

IN CASE OF EMERGENCY, NOTIFY:

Name

Relationship

Phone

Address

“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, AND UNDERSTAND THAT IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.

I UNDERSTAND AND AGREE THAT IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED WITHOUT PRIOR NOTICE OR CAUSE

Please click the checkbox at the right to state: "I agree with all terms and conditions of this application".

eMail Address

Date

Resume Submission

Note: This is a two ( 2 ) part application. Please complete both parts.