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Employment Application

Referral Source: Cell Phone
Full Name: Email:
Driver's License / State ID #: SSN:
Date: Years Residing in Indiana:
Present Address
City: State: Zip:
Former Address
City: State: Zip:
Employment Info
Employment Desired:            
Date You Can Start:
Employed Now?
May we contact your employer?
Applied here before? When? Where?
Are you on layoff and subject to recall?
Will you travel if required?
Will you work a 12-hour night shift?
Will you work if short notice?
Do you have all required documents for this position?
Have you ever been injured?
Criminal History
Convicted of a felony in last 7 years?
If no, skip to next section.
Such conviction may be relevant if job related, but does not bar you from employment. If yes – explain:
Driver's License No. State:
Type School Name & Location # of Years Completed Did You Graduate? Subjects Studied
Academic Currently Attending

Last Completed

Professional: RN, HHA, CNA, PT, OT, SP, Other Currently Attending
Last Completed

Employment History
Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company.
Work History:
Dates Employer Name and Address Salary Job Reason for Leaving

Give the names of three persons not related to you whom you have known at least 1 year.
Name Address Phone Years Acquainted
Foreign Languages
List any foreign language(s) and check the box that best describes your skill level.
In Case of Emergency, Notify:
Conditions of Employment – please read carefully

Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

I give the employer the right to investigate all police, driving, and personal records and references, if job related.  I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer.  The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company.

Panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.


General Comments: