Employment Application Form

Samaritan House, as an equal opportunity employer, complies with all applicable federal and state laws regarding
nondiscrimination. Samaritan House is committed to a policy of equal opportunity for all persons and does not
discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity,
gender expression, disability, religion, or veteran status in employment, services, and volunteer opportunities.

Date ^*

Name ^*

First Name ^*

Last Name ^*

Middle Name

Maiden

Present address ^*

How long ^*

Telephone ^*

Position applied for (1) ^*

Position applied for (2) ^*

Have you ever applied with us before? ^*

Have you ever been employed with us before? ^*

How did you learn about us? ^*

How many hours can you work weekly? ^*

Can you work nights? ^*

Employment desired ^*

On what date would you be available for work? ^*

Indicate any foreign language you can speak. ^*

TYPE OF SCHOOL	NAME OF SCHOOL	LOCATION(Complete mailing address)	NUMBER OF YEARS COMPLETED	MAJOR & DEGREE
High School
College
Bus. or Trade School
Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME? ^*

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation.

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation.^*

Do You Have a Driver's License? ^*

Driver’s license number

Driver’s license number ^*

State of issue

Expiration date

Expiration date^*

What is your means of transportation to work? ^*

Have you had any accidents during the past three years? ^*

How many accidents?

How many accidents? ^*

Have you had any moving violations during the past three years? ^*

How many?

How many? ^*

Please list four references other than relatives or previous employers.

First Reference

Name ^*

Position ^*

Company ^*

Address ^*

Phone ^*

Email address ^*

Second Reference

Name ^*

Position ^*

Company ^*

Address ^*

Phone ^*

Email address ^*

Third Reference

Name ^*

Position ^*

Company ^*

Address ^*

Phone ^*

Email address ^*

Fourth Reference

Name ^*

Position ^*

Company ^*

Address ^*

Phone ^*

Email address ^*

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.

MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES? ^*

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? ^*

Specialty ^*

Date Entered ^*

Discharge Date ^*

Work Experience: Please list your work experience for the past ten years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last supervisor

Employment dates

Pay or salary

From
To

Start
Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last supervisor

Employment dates

Pay or salary

From
To

Start
Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

Work Experience: Please list your work experience for the past ten years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last supervisor

Employment dates

Pay or salary

From
To

Start
Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer
Address
City, State, Zip Code
Phone number

Name of last supervisor

Employment dates

Pay or salary

From
To

Start
Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.

May we contact your present employer?

APPLICANT'S STATEMENT:

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all
statements contained in this application for employment as may be necessary in arriving at an employment decision. This
application for employment shall be considered active for a period of time not to exceed 30 days.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this
organization is of an "AT WILL" nature, which means that the employee may resign at any time and the employer may
discharge employee at any time with or without cause. It is further understood that this "AT WILL" employment relationship
may not be changed by any written document or conduct unless such change is specifically acknowledged in writing by an
authorized representative of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may
result in discharge. I understand also, that I am required to abide by all rules and regulations of the employer. I hereby give
permission for Samaritan House to complete a background check and verification of references.

Date ^*