Employment Application

Sitters Etc. Application for Employment Equal Opportunity Employer

First Name
Last Name
Middle Initial
Address
City
State
Zip
Home Phone
Mobile
Email
Former Employer 1
Company Name
From Date
To Date
Phone Number
Position/Reason for Leaving
Rate of Pay
Former Employer 2
Company Name
From Date
To Date
Phone Number
Position/Reason for Leaving
Rate of Pay
Former Employer 3
Company Name
From Date
To Date
Phone Number
Position/Reason for Leaving
Rate of Pay
Education
List degrees, certifications, special skills, caregiving experience, etc.
References
First Reference Name
Phone
Years Known
Second Reference Name
Phone
Years Known
Third Reference
Phone
Years Known
Authorization
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
Digital Signature
Date

Employment Application

Employment Application

Former Employer 1

Former Employer 2

Former Employer 3

References

Authorization

Services

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