Personal Information s5

Updated 11/9/12

EMPLOYMENT APPLICATION

Personal Information Date:______Name:______Last, First, Middle Initial Present Address: Street, (unit # or Apt # if applicable) City, State, Zip Code Daytime Telephone Number:______Cell Phone: ______

Referral Source: ______

Employment Availability Position Applying For:______Date Available to start work:______Pay Expected: ______Please circle all days available for work: Mon. Tues. Wed. Thurs. Fri. Sat. Sun Times ______Were you previously employed by Full Life Care? _____Yes_____No If yes, when and what position did you hold?______

Employment History Begin with most recent position held. Include military service assignments. If you include volunteer activities, you may exclude those indicating race, color, religion, national origin, disability or other protected status. Please provide an updated resume if available.

1.Name of Employer:______Address:______Dates Employed: From:______To:______City, State & Zip:______Job Title:______Duties:______Salary-Start:______Final:______Reason for Leaving:______Supervisor’s Name:______Phone Number:______May we contact the Supervisor for reference purposes? _____Yes _____No 2. Name of Employer:______Address:______Dates Employed: From:______To:______City, State & Zip:______Job Title:______Duties:______Salary-Start:______Final:______Reason for Leaving:______Supervisor’s Name:______Phone Number:______May we contact the Supervisor for reference purposes? _____Yes _____No 3. Name of Employer:______Address:______Dates Employed:From:______To:______City, State & Zip:______Job Title:______Duties:______Salary-Start:______Final:______Reason for Leaving:______Supervisor’s Name:______Phone Number:______May we contact the Supervisor for reference purposes? _____Yes _____No

Will you be able to perform the essential functions of the job, with or without reasonable accommodation? ______Yes ______No Education & Credentials Name of School Location Degree Received Area(s) of Study ______High School ______Trade/Professional ______College/University ______Graduate School ______

Please list any additional job-related qualifications and skills, training, experience, extra-curricular activities, credentials:______

References Provide below the names of three persons who know your work style and history (for example, current or past supervisors, co- workers, instructors, etc.) and who are otherwise not related to you. At least two professional references must be listed. Giving this information means you give Full Life permission to contact the reference listed in order to obtain accurate dates of employment, job performance and any additional valued past employment information.

Employer Reference Reference #1 Name:______Relationship to you:______Organization:______City:______Daytime Phone:______E-mail: ______Reference #2 Name:______Relationship to you:______Organization:______City:______Daytime Phone:______E-mail: ______Reference #3 Name:______Relationship to you:______Organization:______City:______Daytime Phone:______E-mail: ______

Please answer the following questions: (NOTE: All Full Life prospective candidates will have background checks done.) 1. Have you ever been convicted of a sex offense? ______Yes ______No 2. Have you been convicted of a felony or misdemeanor? ______Yes ______No 2. Can you provide documentation that you are ______Yes ______No eligible for employment in the United States? 3. May we contact your present employer? ______Yes ______No 4. Are you at least 18 years of age? ______Yes ______No

I certify that answers given in this application are true and complete to the best of my knowledge. I authorize investigation into all statements I have made on this application as may be necessary for reaching an employment decision. I authorize Full Life to perform ‘due diligence,’ in its background and reference checks prior to my possible employment. In the event I am employed, I understand that any false or misleading information I knowingly provide in my application or interview(s) may result in discharge and/or legal action. I understand that Full Life is an at-will employer. I understand also that if employed, I am required to abide by all rules and regulations of the employer and any special agreements reached between the employer and me.

Signature:______Date:______

If you need special accommodations to complete the application form, please call (206) 224-3769 for assistance. Full Life Care is an Equal Opportunity Employer.