Preliminary Employment Application

Name:

Address:

City:

State:

Zip:

Date:

Position Applying For:

Date Available:

Social Security #:

Over 18 Yrs.:

Company Name:

Phone:

Name:

Phone:

Hours/Days Available:

Supervisor/Contact:

Dates Employed:

Company Name:

Company Name:

Supervisor/Contact:

Supervisor/Contact:

Dates Employed:

Dates Employed:

Phone:

Phone:

Position:

Position:

Position:

Employment History:

Personal References:

List 3 people not related to you, whom you have known at least 1 year.

Starting with most recent, please list previous employment.

Reason Leaving

Reason Left:

Reason Left:

Yrs Acquainted:

Name:

Name:

Phone:

Phone:

Yrs Acquainted:

Yrs Acquainted:

Have you ever been convicted of a felony?:

Do you have a valid drivers license?:

Do you have current automobile insurance coverage?:

*You must maintain a valid drivers license and automobile insurance coverage at all times to be eligible to work at Advantage.

**Please note that this is a preliminary employment application only.  You may be asked to complete a full application.  Neither application constitutes an employment offer, contract, or modification to the at-will employment relationship between yourself and Advantage.

Phone:

E-mail:

If applying as a Home Health Aide, are you State Tested?

Number of years experience in Home Care:

Highest Education Completed:

Other Training/Education: