Friends Who Care

HHA
EMPLOYMENT APPLICATION

 

Use "TAB" key to move to each field.  This will insure no information is missed.
Name:      SS#:     Date:  
Address:    Email: 
City:    State:     Zip: 
Phone:   Drivers License #: State: 
Position Desired:
EDUCATION NAME/ADDRESS MAJOR FROM/TO GRADUATE DEGREE
High School:
College:
College:
Graduate School:
Additional Education:
License, Registration, Certificates:
Are you a student? Yes No How soon are you available for employment?
Are you 18 years or older? Yes No Salary requested:
Are you under a physician's care? Yes No Method of transportation: 
Do you have any physical, mental or medical impairments or illnesses which may interfere with your ability to work the position which you applied for?  If yes, explain below.  

Yes No

 Do you own a car?

Year/Make
Auto Insurance Company

Have you ever received Worker's Compensation?  If yes, explain below.		 Yes No



Yes No
Have you ever been convicted of a crime?  If yes, explain below. Yes No Have you ever been employed under a different name?  If yes, what? Yes No
Are you available for positions other than for what you have applied? Yes No
Are you available for weekends? Yes No

 

Please list the hours which you will be available for work:

 

List any volunteer experience, skills, hobbies, interests:

 

List any duties you are unwilling/unable to perform:

 
List 3 character references, not related to you:

NAME ADDRESS PHONE TITLE

Please list previously held positions.  Include present employment if you are now employed.  Begin with you most recent position.
EMPLOYER:        
ADDRESS:           
PHONE:                    TITLE:  
TYPE OF BUSINESS:     SALARY: 
SUPERVISOR:             
DATES OF EMPLOYMENT:    From       To 

DUTIES:
                

REASON FOR LEAVING:
                

********************************************************************************

EMPLOYER:        
ADDRESS:           
PHONE:                    TITLE:  
TYPE OF BUSINESS:     SALARY: 
SUPERVISOR:             
DATES OF EMPLOYMENT:    From       To 

DUTIES:
                

REASON FOR LEAVING:
                

*******************************************************************************

EMPLOYER:        
ADDRESS:           
PHONE:                    TITLE:  
TYPE OF BUSINESS:     SALARY: 
SUPERVISOR:             
DATES OF EMPLOYMENT:    From       To 

DUTIES:
                

REASON FOR LEAVING:
                

 
This is a good time to print the application you have completed.

Then proceed and submit.
I certify that the statements on this document are true to the best of my knowledge.  I realize that all the information furnished by me is important and that Friends Who Care will rely on this information in engaging me and continuing my employment.  I also realize that this information may be verified, and any misrepresentation of facts may constitute cause for dismissal.  In this connection I authorize all previous employers to cooperate with this agency and to release on a confidential basis any information they may have concerning me.  I agree to abide by all agency rules and regulations.


             2770 Carpenter Rd. Suite 200  Ann Arbor, Michigan  48108
            Phone:  734-971-6300 Fax: 734-971-1026
 

Copyright © 2002-2008 by Friends Who Care, Inc.