2100 W. Laburnum Avenue, Suite 104B Richmond, VA 23227
(804) 340-1845 (804) 340-1848 fax
www.supportone.org EMPLOYMENT APPLICATION
We are an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, creed, religion, national heritage, sexual orientation, disability, marital status, and any other legally protected status. It is our policy to abide by all Federal, State, and, local laws concerning discriminating in employment. No question in this application is intended to elicit information in violation of any such law nor will any information obtained in response to any question be used in violation of any such law.
Position Applied For: ______Date: ______
Full Name: ______SSN: ______
Address: ______Home Phone: (_____)______
______Work Phone: (_____)______
City State Zip Code
EDUCATION
Do you have a high school diploma or GED ______Yes ______No Year Completed: ______
Additional Education:
Name and location of Institution / Degree / Major / Minor / DatesADDITIONAL INFORMATION
Which of the following options would you consider? ____ Full time ____ Part time ___ Relief ___Volunteer
Are you willing to work overtime? ____Yes ____No Do you have a valid VA Driver’s License? ____Yes ____No
Are you currently authorized to work in the United States on a full-time basis for any employer? _____Yes ___No
If no, what is your current immigration status______
Have you ever been convicted in a court of law for any reason other than a minor traffic offense? ____Yes ____No
If yes, please explain (including conviction, jurisdiction, date, etc.)______
Do you have any moving violations on your driving record? Explain:______
How did you learn about our organization and/or this opening? 5 Referral 5Newspaper 5Website 5Other ______
Please check the following certifications that you possess: _____ CPR ______Exp. Date
_____ Medication Administration _____ First Aid ______Exp. Date
_____ Medicaid Waiver _____ TOVA ______Exp. Date
EXPERIENCE
List Present and Former Employers beginning with the most recent or positions with applicable experience
Company Name: ______
Address: ______Dates Employed: From ______to ______
Supervisor: ______Phone Number: (____)______
Title & Description of Duties______May we contact: ______Yes ______No
______Wages: ______Start ______Last
______Reason for Leaving: ______
EXPERIENCE Cont.
Company Name: ______
Address: ______Dates Employed: From ______to ______
Supervisor: ______Phone Number: (____)______
Title & Description of Duties______Wages:______Start______Last
______Reason for Leaving:______
______
Company Name: ______
Address: ______Dates Employed: From ______to ______
Supervisor: ______Phone Number: (____)______
Title & Description of Duties______Wages:______Start______Last
______Reason for Leaving:______
______
Company Name: ______
Address: ______Dates Employed: From ______to ______
Supervisor: ______Phone Number: (____)______
Title & Description of Duties______Wages:______Start______Last
______Reason for Leaving: ______
______
Attach additional sheet if necessary
SKILLS AND QUALIFICATIONS
Do you have any other experiences or qualifications, in addition to those listed above, which relate to the job for which you are applying? If so, please describe. ______
______
APPLICANT’S CERTIFICATION – Please read carefully before signing
I certify that, to the best of my knowledge and belief, the answers given by me to the foregoing questions and the statements made by me in this application are correct and complete. I understand that misrepresentation or omission of facts in this application may result in my discharge. I authorize you to communicate with those employers I have listed, school officials, law enforcement personnel, and the persons named as references concerning my skills, education, character, and responsibility. If employed, I understand and agree that such employment may be terminated at any time, without prior notice, and that my employment will not be governed by any expressed or implied contract but is employment at-will.
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Applicant’s Signature Date