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

    [cf7mls_step step-1 “Next”]

    Please list four references other than relatives or previous employers.

    First Reference

    Second Reference

    Third Reference

    Fourth Reference

    [cf7mls_step step-2 “Back” “Next”]

    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.

    [cf7mls_step step-3 “Back” “Next”]

    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.