Date

First Name

Home Phone

Present Address

E-mail

Age

Position applying for:

Are you applying for?

Shifts Desired:

For Specialty Nurses Only:

If hired, on what date can you start work?

Name, address and telephone number of person to be notified in case of an accident or emergency.

Have you ever applied to work for AAA T.L.C. Health Care, Inc. before?                yes no  

If yes, when?

Do you have any friends or relatives working for AAA T.L.C. Health Care, Inc.?        yes no

If yes, state name(s) and relationship

How did you learn of this job opening?

If hired, would you have a reliable means of transportation to and from work?

no yes

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

yes no

Can you perform the essential functions of the position for which you are applying?  yes no

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?

yes no

If yes, state the nature of the crime(s), when and where convicted and disposition of the case.

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature ofthe offense, thedate of the offense, the surrounding circumstances and the relevance of the offense to the position(s)applied for may, however, beconsidered.)

Military experience in armed forces of the U.S. or in a state militia (U.S.).

Service Branch

Final Rank

Initial Rank

Speciality  

School

Name and Address

Did you Graduate?

No. Years Complited

Degree Diploma

High School

yes no

Vocational/ Business

yes no

College/ University

yes no

Graduate

yes no

Can you furnish records of completion of schools and/or courses as indicated above?

yes no

Do you have any other experience, training, qualifications or skills, which you feel make you especially
suited for work at AAA T.L.C.? If so, please explain:

List professional, trade, business or civic activities and offices held.

Note: You may exclude memberships, which would reveal sex, race, color, religion, national origin, age,ancestry, medical condition sexual orientation, disability or any other legally protected status.

Are you licensed/certified for the job applied for?

yes no

Professional Lic. No.

Exp. Date

State

Type of Lic.

Professional Lic. No.

Exp. Date

State

Type of Lic.

Professional Lic. No.

Exp. Date

State

Type of Lic.

Has your license/certification ever been revoked or suspended?

yes no

If yes, state reason(s), date of revocation or suspension and reinstatement:

PLEASE CHECK CERTIFICATIONS HELD:

I understand consideration for employment with AAA T.L.C. will be contingent upon the results ofreference and criminal background checks. I authorize AAA T.L.C. to investigate all information I provideon this application for employment, including previousemployment, experience and educational credentials.I also give AAA T.L.C. permission to contact my former employer(s), all listed references or any otherperson who can verify the information I provide on this application. I hereby authorize and direct mycurrent and former employers and other contacted persons to respond to any questions pertaining to theinformation included on this application.

NAME

DATE

List below all present and past employment starting with your most recent employer (previous 5 years issufficient). Account for all periods of unemployment. You must complete this section even if attaching aresume.

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