Careers Form

* = Required Information

PERSONAL INFORMATION

First Name *

Last Name *

Social Security *

Date of Birth *

Address *

Apt # *

City *

State *

Zip code *

Mailing Address *

Home Phone *

Cell Phone *

Alternate Phone

Emergency Contact

Address

Phone

Are you 18 or older? (If no, we will verify your legal age to work)

Yes

Gender

Female

Male

Are you an U.S. Citizen or alien authorized to work in the United States?

Yes

Position (s) applying for

Salary/ Wage desired

Have you ever been employed by N2 Care Services?

Yes

Give dates employed

How did you hear about us?

On what date, are you available to work?

Have you ever been convicted of a felony?

Yes

EDUCATION/SKILLS

1. High school

No. of Years attended

Location

Phone

Did You Graduate or Obtained Degree?

Yes

Subject

2. College

No. of Years attended

Location

Phone

Did You Graduate or Obtained Degree?

Yes

Subject

3. Trade, Business or Correspondence School

4. List any experiences, special skills or qualifications that would be of special benefit to the Job for which you are applying for

PROFESSIONAL LICENSES AND OR CERTIFICATES

1. Organization

Phone

State Issued

Date Issued

2. Organization

Phone

State Issued

Date Issued

CURRENT EMPLOYMENT

Are you currently employed?

Yes

We routinely can contact an applicant's current employer for references checks. Would this Pose a particular difficulty for you.

Yes

Please explain

EMPLOYMENT HISTORY

Please provide three most recent employment histories.

1. Current or last employer

Employer

Phone

Address

From

Supervisor

Weekly Wages

Position & Duties

Reason for Leaving

2. Current or last employer

Employer

Phone

Address

From

Supervisor

Weekly Wages

Position & Duties

Reason for Leaving

3. Current or last employer

Employer

Phone

Address

From

Supervisor

Weekly Wages

Position & Duties

Reason for Leaving

4. Please explain all periods of unemployment

5. Have you ever been terminated from employment?

Yes

Please explain

REFERENCES

1. Name

Phone

Address

Yrs. Acquainted

2. Name

Phone

Address

Yrs. Acquainted

3. Name

Phone

Address

Yrs. Acquainted

TRANSPORTATION

The following section must be completed if you are applying for a position that requires the operation of a motor vehicle, owned or leased by the agency, or if you must use your own vehicle for agency purposes.

1.Driver's License #

State Issued

Exp. Date

2.Do you have auto liability insurance?

Yes

Give name of insurance company and expiration date

Name

Exp. Acquainted

3.Has your driver's license ever been suspended or revoked for any reason?

Yes

Give date(s) and the severity of the incident(s)

Date

Incident

TRAFFIC VIOLATIONS RECORD

List the traffic citations that you have received during the last five (5) years preceding date of this Application, and state the disposition of each, as "dismissed", "paid fine", "defensive driving", etc.

1.Date

Type

Disposition

2.Date

Type

Disposition

3.Date

Type

Disposition

If you have been driving while intoxication or under the influence, please explain:

NOTE: If you are hired for a position that requires driving, you must keep us informed of Any changes in your driving record.

NOTICE TO PROSPECTIVE EMPLOYEES

N2 Care Services is an equal opportunity employer and complies with all federal and state laws pertaining to employment.

The health and safety code, Section 533.007, allows this agency to check conviction records of applicants. Certain convictions will disqualify you from employment.

N2 Care Services will check the background of all applicants to determine if the applicant has comfirmed allegation of abuse, neglect or exploitation and will not hire anyone with a confirmed case.

Do you have physical and/or mental capability to perform the essential functions of the Job?

Yes

State the accommodations that would allow you to perform the job:

APPLICANT STATEMENT
By submiting this application, I certify that answers given herein on this application is true, correct and complete to the best of my knowledge. I also certify that I have accounted for all my work experience and training on this application, and I have not knowingly withheld any fact or circumstance, which I would have disclosed. N2 Care Service is hereby authorized to make any investigation of my employment, educational, credit or criminal history through any investigative agencies or bureaus of its choice. I release all relevant parties from all liability of any damages resulting from furnishing such information. I understand that I must be capable to perform the essential functions of the job for which I am applying. I understand that my employment is subject to mobility Evaluation and I understand that my employment may be conditioned upon maintaining a favorable drug/alcohol screening. I also agree that all information concerning said physical examination can be supplied to the authorized agent of this agency, upon request. If employed by N2 Care services, I agree to abide by its rules and regulations. I understand discovery of misrepresentation or omission of facts herein will be cause for immediate dismissal. I authorize N2 Care Services to make any inquiry as required to complete my employment file. I understand that operating conditions may require me to temporarily or parmenently work shifts other than the one for which I am applying and I agree to such scheduling Changes as directed by my supervisor. I further understand that this application for employment is not an employment Contract. I Understand that if employed such employment is for an indefinite period and can be terminated at will by either party, with at least a two weeks notice in writing,at any time, for any or no reason, and is subject to change in wages, conditions, benefits, and operating policies. If employed, I will be required to complete an employment verification form and also show satisfactory evidence of identity and eligibility for employment within five days.

Date *

Signature *