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? * NoYes
Have you ever been employed with us before? * NoYes
How did you learn about us? *
How many hours can you work weekly? *
Can you work nights? * NoYes
Employment desired * Full-time onlyPart-time onlyTemporaryShift Work
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? * NoYes
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? * NoYes
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? * NoYes
How many accidents?
How many accidents? *
Have you had any moving violations during the past three years? * NoYes
How many?
How many? *
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Please list four references other than relatives or previous employers.
First Reference
Position *
Company *
Address *
Phone *
Email address *
Second Reference
Third Reference
Fourth Reference
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.
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HAVE YOU EVER BEEN IN THE ARMED FORCES? *NoYes
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? *NoYes
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.
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May we contact your present employer?NoYes
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.