M&Y Extraordinary Care HCS

M&Y Extraordinary Care HCS

EMPLOYMENT APPLICATION

An equal opportunity Employer.

PERSONAL

NAME______

Last First Middle

Address______

Street City State Zip Code

Telephone ______Social Security Number ______-______-______

Area Code

Driver’s License Number______State______Expiration Date______

Have you ever been convicted of a felony Yes No Explain Felony______

In the last seven years?______

Are you a citizen of the Unites States? Yes No

JOB INTRESTS SKILLS______

Position(s) applied for______Salary Desired______

Have you applied for a position here before? Yes No If yes, when ?______

Type of employment requested: Full Time Part Time Temporary Summer

Date available to begin working ______

Typing speed WPM)______

Summarize any other special skills and qualifications:

______

EDUCATION______

Type of School /

Name and Location

/ Course of Study / # Of Years / Grade

Average

/ Maximum Grade /

Degree, Diploma

Certificate and honors received
High School
College of University
Other Education
Other Education

EMPLOYMENT HISTORY (LIST MOST RECENT FIRST)

Name of Employer______

Address______

Street City State Zip Code

Supervisor and Title______Your Title______

Employed From______To______Starting Salary______Ending Salary______

Work Performed______

Reason for Leaving

Name of Employer______

Address______

Street City State Zip Code

Supervisor and Title______Your Title______

Employed From______To______Starting Salary______Ending Salary______

Work Performed______

Reason for Leaving

Name of Employer______

Address______

Street City State Zip Code

Supervisor and Title______Your Title______

Employed From______To______Starting Salary______Ending Salary______

Work Performed______

Reason for Leaving

REFERENCES

Name / Relationship / Home Phone / Daytime phone

ACKNOWLEDGEMENT

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I certify that the answers given by me in this application are correct to the best of y knowledge. I understand that any falsification of this application, whether willingly or accidental, is grounds for disqualification of employment consideration, or dismissal from employment if I am hired. I authorized the company to contact any and all of the references I have listed above to obtain previous employment information or any other pertinent information that they may have. Further, I released the above mentioned references from any and all liability for any damages that may results from information collected by the by this company. Verification of eligibility to work in the United States must be satisfied for an offer to be made.

Applicant’s Signature______Date______