Employment Form

* = Required Information

Name *

D.O.B *

SSN

Address *

Home Phone *

Cell Phone *

Work Phone *

Email *

Position applying for *

Desired Hours/Week

Are you at least 18 years or older?

Yes

Please put a check in the corresponding box to indicate times you will be available to work.

Day

Eve

Night

PRN

If you are hired, when can you start work?

How did you hear about this job opening?

Do you possess a valid driver's license?

Do you have reliable transportation?

Do you have any criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo-contendere except minor traffic offenses.

Yes

Please provide details of the offense(s), conviction(s), location(s), date(s), and disposition(s) in the space provided

Have you ever been known by any other name(s) aliases and or social security numbers?

Yes

Please list name(s) and or social security numbers utilized

Are you on the Missouri Employee Disqualification List

Yes

Education
Please check the highest level achieved

Please indicate the high school(s) and colleges (if applicable), you have attended,

(1)

School Name

Address

# of Years Attended

Degree/Major

(2)

School Name

Address

# of Years Attended

Degree/Major

(3)

School Name

Address

# of Years Attended

Degree/Major

(4)

School Name

Address

# of Years Attended

Degree/Major

Please list related course work, certifications or achievements below

Employment History
Please list below previous employers, starting with the most recent

(1)

Employer Name *

Employer Address *

Employment Dates

From

Job Title *

Supervisor Name *

Phone Number

Reason for Leaving

(2)

Employer Name

Employer Address

Employment Dates

From

Job Title

Supervisor Name

Phone Number

Reason for Leaving

(3)

Employer Name

Employer Address

Employment Dates

From

Job Title

Supervisor Name

Phone Number

Reason for Leaving

Please list three references. References must be former employers or other knowledgeable persons, excluding relatives.

(1)

Name *

Address

Phone

Relationship

(2)

Name *

Address

Phone

Relationship

(3)

Name *

Address

Phone

Relationship

I verify that the statements I have made in this application are true and complete. I understand that it is a class A misdemeanor to knowingly fail to disclose my criminal history. I understand that if I am hired, any false or incomplete statements in this application will be grounds for immediate discharge. I have read and understand the following statements:

- I hereby acknowledge that I will be required to register with the Family Care Registry within 15 days of hire date if hired, which will do a complete background check for offenses which may disqualify an applicant from being hired.

- I hereby consent to a pre-employment criminal record check

- I hereby consent to a closed records check pursuant to Section 610.210 RSMo

- I hereby acknowledge that additional background checks may be conducted as well.

- I hereby acknowledge that Agape Quality Care, LLC is an At-Will Employer.

- I hereby acknowledge that this application does not constitute a promise of employment with Agape Quality Care, LLC

Applicant Signature Date *