Employment Application

Personal Information

First, Middle & Last Name

Email Address

Phone

Present Street Address, City, State, Zip Code

Permanent Street Address, City, State, Zip Code

Name & department of any relative, other than spouse, already employed by Foss Home & Village

Referred to Foss Home & Village by
—Please choose an option—AdvertisementFriendRelativeWalk-inEmployment AgencyOther

If you selected "Other", please list referral.

Available to work
Full-timePart-timeOn-callTemporary

Can you work weekends?
YesNo

On what date would you be available to start work? (mm/dd/yyyy)

Desired Employment

Position

Shift Preferred
AMPMNight

Salary Desired

Are you employed now?
YesNo

If yes, may we inquire of your present employer?
YesNo

Have you ever been employed here before?
YesNo

If yes, give dates. (mm/dd/yyyy)

Are any of your records under a different name?
YesNo

If yes, give name(s).

If you are under 18 and are employed, can you show a work permit?
YesNo

Education

High School

Name & Location of School

Years Completed
—Please choose an option—01234

Graduated?
YesNo

Subjects Studied & Degree(s) Received

College

Name & Location of School

Years Completed
—Please choose an option—01234

Graduated?
YesNo

Subjects Studied & Degree(s) Received

Other Education

Describe Specialized Training, Apprenticeship, Skills, & Other Activities

Former Employment or Volunteer Positions

List your last 4 employers below, in order of most recent.

Employer 1

Employer 1 Name & Address

Employer 1 Phone Number

Employer 1 Supervisor Name

Employer 1 Start Date (mm/dd/yyyy)

Employer 1 End Date (mm/dd/yyyy)

Employer 1 Position

Employer 1 Reason for Leaving

Employer 2

Employer 2 Name & Address

Employer 2 Phone Number

Employer 2 Supervisor Name

Employer 2 Start Date (mm/dd/yyyy)

Employer 2 End Date (mm/dd/yyyy)

Employer 2 Position

Employer 2 Reason for Leaving

Employer 3

Employer3 Name & Address

Employer 3 Phone Number

Employer 3 Supervisor Name

Employer 3 Start Date (mm/dd/yyyy)

Employer 3 End Date (mm/dd/yyyy)

Employer 3 Position

Employer 3 Reason for Leaving

Employer 4

Employer 4 Name & Address

Employer 4 Phone Number

Employer 4 Supervisor Name

Employer 4 Start Date (mm/dd/yyyy)

Employer 4 End Date (mm/dd/yyyy)

Employer 4 Position

Employer 4 Reason for Leaving

References

List below the names of 3 persons, not related to you, whom you have known at least 1 year.

Reference 1

Reference 1 Name & Address

Reference 1 Phone

Reference 1 Business

Reference 1 Years Acquainted

Reference 2

Reference 2 Name & Address

Reference 2 Phone

Reference 2 Business

Reference 2 Years Acquainted

Reference 3

Reference 3 Name & Address

Reference 3 Phone

Reference 3 Business

Reference 3 Years Acquainted

English

Indicate your understanding and ability to read, write and speak English.

Read
—Please choose an option—ExcellentGoodPoorNot at All

Write
—Please choose an option—ExcellentGoodPoorNot at All

Speak
—Please choose an option—ExcellentGoodPoorNot at All

Licensure or Certification

Type

State

Number

Expiration

Emergency

In case of emergency, please list a person below.

Emergency Contact Name

Emergency Contact Phone

Background Check Authorization

Please review the Background Check Authorization form. You will be asked to fill this out before employment.

Resume

Please upload your resume as a PDF or Word document (optional).

Terms & Conditions

All job applications or rehires will undergo testing for the presence of illegal drugs and marijuana as a condition of employment.

I AUTHORIZE the company to investigate and verify any information contained in my application or pre-hire interviews, including my previous employment, education, background, licenses, certifications and driving record (as required for the position for which I applied). I further release all parties from all liability for any damage that may result from furnishing or receiving such information.

I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated at any time without previous notice.

Application is kept active for 90 days.

I accept these Terms & Conditions.

Electronic Signature (please enter name in field below)