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APPLICATION FOR EMPLOYMENT
We are an equal employment opportunity employer. All prospective employees will receive consideration without
discrimination because of race, color, religion, sex, national origin, citizenship, age, marital status, disability, or
other classification protected by law. All information provided herein will be kept confidential.
Last Name First Name Middle Name Social Security #
Current Address (Street, City, State, Zip) Home Phone #
Previous Address (Street, City, State, Zip) if current is less than 5 years Alternative Phone #
@
Email Address
Have you ever worked or attended school under another name? Yes No
If yes, please list all names:
Have you ever applied for employment with this Agency? Yes No
Were you previously employed with this Agency? Yes No
Are you legally eligible for employment in the United States? Yes No
How did you learn of our organization? _____Online _____Newspaper _____Employee referral
_____Other:
Name of Source:
How many hours per week are you available for work?
Are there any days or times that you cannot work?
Do you have an active Florida drivers license and auto insurance? Yes No
Do you have reliable transportation? Yes No
Date available: Hourly/Salary requirement:
Position applying for (circle): RN LPN CNA HHA PT OT ST MSW
Other:
Page 1 of 5
EDUCATION:
Type Name & City/State of School # of years Degree Awarded Major
High School
Trade, Business, etc.
College
Graduate
EMPLOYMENT:
List all present and past employment for the previous 5 years, starting with your most recent employer.
Company: Job Title:
Dates of employment: May we contact employer? Yes No
Address:
Supervisor: Telephone #:
Describe duties in detail:
Reason for leaving: Pay rate: hourly/annually
Company: Job Title:
Dates of employment: May we contact employer? Yes No
Address:
Supervisor: Telephone #:
Describe duties in detail:
Reason for leaving: Pay rate: hourly/annually
Company: Job Title:
Dates of employment: May we contact employer? Yes No
Address:
Supervisor: Telephone #:
Describe duties in detail:
Reason for leaving: Pay rate: hourly/annually
Company: Job Title:
Dates of employment: May we contact employer? Yes No
Address:
Supervisor: Telephone #:
Describe duties in detail:
Reason for leaving: Pay rate: hourly/annually
Page 2 of 5
PROFESSIONAL REFERENCES:
Please provide three references that can furnish information about job performance.
Name: Phone:
Company: Position/Relationship:
Address:
Name: Phone:
Company: Position/Relationship:
Address:
Name: Phone:
Company: Position/Relationship:
Address:
CRIMINAL HISTORY:
Have you ever been convicted of, pled guilty or no contest (nolo contendere) to a criminal offense, regardless of
whether adjudication was withheld and whether your record has been sealed? Yes No
Do you have any criminal charges pending? Yes No
If yes to either question, explain all details such as the nature of charge(s), date(s), location(s), etc.
Note: Conviction will not necessarily disqualify an applicant from employment, but the information will be
considered in relation to the position that you are seeking. Attach a separate page if additional space is needed.
DRIVERS LICENSE / DRIVING RECORD:
Drivers License #: State of Issue:
Expiration Date:
Have you had any accidents during the past three years? If yes, how many?
Have you had any moving violations during the past three years? If yes, how many?
Page 3 of 5
CREDENTIALS / SPECIALIZED SKILLS / QUALIFICATIONS:
Please summarize all special job-related skills and qualifications acquired from employment or other experience
(i.e. infusion therapy; diabetic educator; certified wound, ostomy, and continence nurse; coding; billing).
Other than English, please list any additional language(s) that you speak:
APPLICANTS ACKNOWLEDGMENT:
I certify that the facts contained in this application are true and complete to the best of my knowledge and
understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize complete investigation of all statements contained herein, including all background screenings and
motor vehicle report, and herby give my full permission for the Agency to contact and fully discuss my
background and history with all persons and entities listed above to give the Agency any and all information
concerning my previous employment and any information they may have, and release all former employees and
others listed above from all liability for any damage that my result from furnishing the same to the Agency.
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 at any time for any lawful reason, without prior notice and with or
without cause.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any
applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not
applications are being accepted at that time.
Signature: Date:
Printed Name:
Page 4 of 5
APPLICANT REFERENCE CHECK
To be completed by applicant:
Applicant Name:
Previous Employer: Contact Person:
Address: Phone:
Fax:
I hereby authorize the following information to be released for all previous employers listed. I release you
and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicants Signature: Date:
To be completed by agency:
Date of employment: From: To:
Position Held: Would you rehire this individual? Yes_____ No_____
Responsibilities:
Reason for Leaving:
Rate of Pay: (weekly/biweekly/salary):
Additional comments (training/skills):
Reference check performed by: Date:
Page 5 of 5
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