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Personal Information |
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| Date
available: |
Month:
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Day:
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Year:
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| First name: |
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| Middle name: |
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| Last name: |
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| Present
street address: |
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| Present
city: |
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| Present
state: |
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| Present zip
code: |
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| Present
telephone number: |
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(if present
address is different than permanent address, please list
it below) |
| Permanent
street address: |
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| Permanent
city: |
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| Permanent
state: |
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| Present zip
code: |
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| Permanent
telephone number: |
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If you can not be reached at
the above phone number, where may we contact you? |
| Name of
contact person: |
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| Contact person
telephone number: |
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Are you a citizen of the U.S.A.? |
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| If no, type
of Visa: |
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| Immigration
number: |
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Employment
Desired |
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| Type of work
desired: |
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| Shift
(hours/days): |
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| Salary: |
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| Will you
accept employment of: |
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| Are you
employed now? |
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| May we
contact your present employer? |
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| If no, why? |
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| Are you at
least 18 years old? |
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| How did you
learn about this opening? |
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Education |
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| Grammar School
Information: |
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| Name of
school: |
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| Location
(city/state): |
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| Courses
taken: |
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Diploma/degree/certificate received: |
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| High School
Information: |
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| Name of
school: |
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| Location
(city/state): |
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| Courses
taken: |
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Diploma/degree/certificate received: |
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| College
Information: |
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| Name of
school: |
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| Location
(city/state): |
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| Courses
taken: |
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Diploma/degree/certificate received: |
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| Vocational or
Business School Information: |
| Name of
school: |
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| Location
(city/state): |
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| Courses
taken: |
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Diploma/degree/certificate received: |
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| Nursing Education
Information: |
| Name of
school: |
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| Location
(city/state): |
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| Courses
taken: |
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Diploma/degree/certificate received: |
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Professional
Licenses and Certifications |
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License/Certification #1 |
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Type: |
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Organization: |
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| Date issued: |
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| Number: |
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License/Certification #2 |
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Type: |
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Organization: |
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| Date issued: |
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| Number: |
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License/Certification #3 |
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Type: |
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Organization: |
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| Date issued: |
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| Number: |
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Employment
Record |
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(List most
recent employment first) |
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| Employer #1 |
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| Name: |
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| Address: |
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| Supervisor's
name: |
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| Telephone
number: |
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| Beginning
date employed: |
Month:
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Year:
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| Ending date
employed: |
Month:
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Year:
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| Starting
salary: |
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| Ending
salary: |
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| Position and
duties: |
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| Reason for
leaving: |
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| Employer #2 |
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| Name: |
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| Address: |
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| Supervisor's
name: |
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| Telephone
number: |
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| Beginning
date employed: |
Month:
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Year:
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| Ending date
employed: |
Month:
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Year:
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| Starting
salary: |
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| Ending
salary: |
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| Position and
duties: |
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| Reason for
leaving: |
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| Employer #3 |
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| Name: |
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| Address: |
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| Supervisor's
name: |
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| Telephone
number: |
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| Beginning
date employed: |
Month:
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Year:
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| Ending date
employed: |
Month:
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Year:
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| Starting
salary: |
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| Ending
salary: |
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| Position and
duties: |
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| Reason for
leaving: |
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| Employer #4 |
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| Name: |
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| Address: |
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| Supervisor's
name: |
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| Telephone
number: |
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| Beginning
date employed: |
Month:
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Year:
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| Ending date
employed: |
Month:
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Year:
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| Starting
salary: |
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| Ending
salary: |
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| Position and
duties: |
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| Reason for
leaving: |
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Please explain all periods of unemployment: |
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| Have you
ever been convicted of a crime? |
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| If so, for
what, when and where? |
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Please use the space below to give us further
information which will help us in placing you. |
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Personal or Professional References #1: |
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Name: |
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| Telephone
number: |
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Personal or Professional References #2: |
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Name: |
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| Telephone
number: |
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Personal or Professional References #3: |
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Name: |
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| Telephone
number: |
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Availability
Record |
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| Are you
available to work weekends? |
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| Are you
available to work on holidays? |
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Do you have responsibilities that would
limit your availability?
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| If yes,
please explain: |
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Does your flexibility allow you to work
if needed on short notice?
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Please indicate the days and hours you are available to
work below: |
| Sunday: |
From:
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To:
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| Monday: |
From:
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To:
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| Tuesday: |
From:
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To:
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| Wednesday: |
From:
|
To:
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| Thursday: |
From:
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To:
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| Friday: |
From:
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To:
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| Saturday: |
From:
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To:
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I voluntarily give HomeChoice the right to make a
thorough investigation of my past employment and
activities, agree to cooperate in such investigation and
release from all liability or responsibility all
persons, companies or corporations supplying such
information. I
understand that HomeChoice follows the fair employment
practice code and there is no discrimination in hiring
of individuals based on sex, race, religion, age or
physical or mental handicap unrelated to ability to
perform the work required.
I understand that I will
be required to follow the personnel policies and rules
of HomeChoice and that infractions of said rules may
lead to dismissal. I also understand that my
employment may be terminated for any misstatement or
omission of fact appearing on this application form.
I give HomeChoice the
right to perform an adult abuse and criminal background
check. |
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| Applications
signature (type name): |
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