Name* Phone Number* Email* Preferred Contact Method -Select One-PhoneEmail How did you hear about Home to Stay? SSN Driver's License/ID Card Number Driver's License/ID Card State
Street City State Zip
In case of an emergency, Home to Stay has my permission to contact:
Name (First and Last) Full Address Relation to You Phone Number Email
Desired Employment -Select One-Full-TimePart-TimeTempSeasonalPRN/Per Diem Desired Position Desired Start Date Desired Salary (per hour) Are you employed now? -Select One-YesNo If so, may we contact your current employer? -Select One-N/AYesNo Have you ever applied to or worked for Home to Stay prior to this application? -Select One-YesNo If so, when? And for/in what position? Will you travel if required? -Select One-YesNo How far (in miles)? Will you work overtime if needed? -Select One-YesNo Are you able to meet the attendance requirements of this position? -Select One-YesNo Have you been convicted of a felony in the past 7 years? -Select One-YesNo If yes, explain (Note: Such conviction may be relevant if job related, but may not bar you from employment.):
Name of School Location of School Did you graduate? -Select One-YesNo Area of Study Certification/Licensure Received
Name of Employer Phone Number of Employer Employed From Employed To Job Title Salary (per hour) Reason For Leaving
Please list 3 persons, not related to you, whom you have known for at least 1 year.
Name Phone Number How/From where do you know them? How many years have you known them?
List any foreign language(s) and select the option that best describes your skill level.
Language Skill Level -Select One-Read, Write and SpeakRead and WriteRead and SpeakSpeak Only
Please read carefully and initial each term of employment. Sign and date at the completion of this application.
Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant/employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separate from the employer’s service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on the basis prohibited by local, state or federal law. Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel or mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce. This application is current for 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. After 60 days, if I have not proceeded forward in the hiring process, it will be necessary to fill out a new application. With my signature below, I attest to the fact that all of the information that I provided on this application is accurate, correct, and truthful to the best of my knowledge.
Please list any explanations from above or any other information:
Signature (enter full name to act as signature) Date
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