Memorial Home Care - Employment Application

Last Name:
First Name:	Middle Name:
Current Address: (number & street)
City:	State: ZIP:
Home Phone:
Cell Phone:
E-Mail Address:
Social Security #

Position Desired:
Specify Clinical Area: (check all that apply)	Medtemp Staffing	Home Care Staffing	HHA
	Private Duty Home Care	Parking Service	CNA
	Correctional	Courier	LPN
	Intermittent Services		RN

Have you worked for us before?	Yes	No When?
Have you worked under another name?	Yes	No Name?

When are you available to work?	Full-Time	Part-Time
	Summer	Temp.
Shift or hours you can work:

Experience Give a complete record of all employment. Start with the most recent employment.
Company Name: Telephone #:
Address (including City, State & Zip):
Employed From & To (Month & Year):
Name of Supervisor:
Weekly Pay:
State Job Title and Job Duties:
Reason for Leaving:

Company Name: Telephone #:
Address (including City, State & Zip):
Employed From & To (Month & Year):
Name of Supervisor:
Weekly Pay:
State Job Title and Job Duties:
Reason for Leaving:

Company Name: Telephone #:
Address (including City, State & Zip):
Employed From & To (Month & Year):
Name of Supervisor:
Weekly Pay:
State Job Title and Job Duties:
Reason for Leaving:
May We Contact Your Present Employer for a Reference?	Yes No

Education
	High School	Vocational/ Technical	Undergraduate	Graduate
School Name & Location
Years Completed
Diploma/Degree

Professional Licenses, Registrations, and/or Certifications
Type:	State Issued:
Exp. Date:	No.:
Type:	State Issued:
Exp. Date:	No.:
Area of Specialization or Major Interest:
Other special training (including on-the-job), skills, experiences or education which increases your value to Memorial:

Please List 3 People You Have Worked With That We May Contact For A Reference
Name:	Address:
Phone:	Occupation:
Name:	Address:
Phone:	Occupation:
Name:	Address:
Phone:	Occupation:

Are you either a U.S. Citizen or an Alien who has the Legal Right to Work? Yes No

According to the Immigration Reform and Control Act of 1986, all applicant must produce documents establishing their identity and authorization for employment in the U.S. These documents must be produced no later than seventy-two (72) hours after commencement of employment. You will also be required to sign an I-9 Form verifying under oath your employment authorization.

Have you served in the U.S. Military? Yes No
Please list job-related skills or experience from the military:

Will you be able to perform the functions and duties of the job which you are seeking?
Yes No
If no, explain why:

Have you ever been convicted of a felony? Yes No
A conviction record will not necessarily be a bar to employment.

How did you happen to apply for work here?

If someone recommended you, please name that person:

Thank you for completing this application form and for your interest in working with us. Memorial adheres to a policy of equal employment opportunity. All employment decisions are made without regard to race, religion, age, sex, color, national origin or handicap and in full compliance with all federal and state laws. Your opportunity for employment with us is based on your merit, past experience and your ability to perform the job. Further, any offer of employment may be conditioned upon the results of a medical examination, including a screening procedure for illegal drugs, which will occur before you begin work.

By clicking the Submit button below, you agree to the following:

I certify that the answers to the questions on this application and the information I have supplied are true and complete to the best of my knowledge. I authorize Memorial to investigate my background and to confirm information contained in this application and I release Memorial and/or any other person, organization or institution from any and all liability that may result from any investigation into my background conducted by Memorial.

I understand that misrepresentation or omission of facts on this application or any other Memorial records will be cause for the rejection of my application or my immediate discharge should I be subsequently employed. Further, I accept that nothing in this application, or in granting of an interview, implies or should be understood as a promise of employment. Also, I understand that should I be subsequently employed by Memorial I have the right to terminate my employment at any time and that Memorial may at its discretion terminate my employment at any time with or without cause.