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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.

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

Please list four references other than relatives or previous employers.

First Reference

Second Reference

Third Reference

Fourth Reference

MILITARY

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.
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.

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.

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