Employment Application

Present Address

Permanent Address

General Information

Educational Data

High School

College

Graduate School

Trade, Business, Night or Correspondence

Other

Licensure #1

Licensure #2

Licensure #3

Employment Experience

(List employment experience, starting with the current or most recent first.)

Employer #1

Employer #2

Employer #3

Employer #4

Special Skills and Qualifications

Additional Skills

References

If you are invited to interview, you will be asked to complete 3 Employment Reference Release forms for 3 people who have supervised your work.

Applicant's Agreement

"I understand and agree that, if I am employed by the Agency, my employment and compensation is entirely "at will," which means neither are guaranteed for any definite period of time, and that either can be modified or terminated, with or without cause, and regardless of the date of payment of my wages and salary, and with or without prior notice at any time, at the option of either the Agency or myself. I understand and agree that the Agency reserves the right to establish and/or change any of the terms or conditions of any aspect of my employment at its discretion at anytime with or without notice. I understand and agree that no other oral or written agreements of any kind pertaining to the terms of my employment and/or my compensation exist outside of this Agreement, and if I believe that any such previous agreements between any Agency representative and myself have been made, I agree they are superseded by the contents of this Agreement. I understand and agree that no representative of the Agency, other than the Chief Executive Officer, or the Board of Directors as a whole, have any authority to enter into any other agreement with me or provide me with any assurances relating to any aspect of my employment with the Agency, except that the above-mentioned officials of the Agency may do so in writing, although the terms of that Agreement cannot contradict the contents of this one. The terms of this Agreement will supersede all others.

I authorize the Agency to investigate my background, qualifications and/or any other information from whomever it deems appropriate. I also authorize anyone the Agency contacts as part of its investigation to release any information they have regarding me or my employment to the Agency or its representatives. Further, I authorize the Agency to release the results of any background checks conducted on me for business reasons to whomever it deems appropriate. I also release all parties from all liability for any damage that may result from either releasing or furnishing this information on me to whomever they deem appropriate. I further agree to take any lawful medical examination, chemical, drug or alcohol test upon request by the Agency at its sole discretion as a condition of my employment, or, if I am hired, as a condition of my continued employment at any time as deemed appropriate by the Agency. I agree that my refusal to take any such examinations or tests immediately upon request may be cause for my not being hired or, if I am hired, may be cause for the immediate termination of my employment. Further, I authorize the Agency to release the results of these tests to whomever it deems appropriate where allowed by law. I hereby release all parties from all liability for any damage that may result from conducting, releasing or furnishing information regarding these examinations or tests.

I also certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if I am employed, any statements I have falsified on this Application shall be grounds for dismissal. I further certify that I have read all of the foregoing understand the same and do hereby voluntarily agree to all of the provisions contained herein."

READ CAREFULLY BEFORE SIGNING

If you are hired, this employment application will become part of your official employment record.