Elite Application for Employment

ELITE APPLICATION FOR EMPLOYMENT

ELITE APPLICATION FOR EMPLOYMENT
Name*

First NameLast Name
Position Applying For*
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you at least 18 years old?*

YesNo
Are you authorized to work in the U.S. on an unrestricted basis?*

YesNo
Are you vaccinated? (People are considered fully vaccinate for COVID-19 ≥ 2 weeks after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna), or ≥ 2 weeks after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Jansen).) Or are you willing to become vaccinated?*

YesNo
How did you learn of this opening?*
Have you worked here before?*

YesNo
Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?*

YesNo
Can you perform these essential functions with or without reasonable accommodation?*

YesNo
Are there any hours, shifts or days you cannot or will not work?*
Shift Preferred
Check all that apply:

Part TimeFull Time
Are you willing to work overtime as required?*

YesNo
Have you ever been convicted of a felony? (Conviction will not necessarily disqualify an applicant for employment)*

YesNo
If yes, describe conditions:
Are you a certified nurse aide (CNA)*

YesNO
If you are a CNA, please provide your CNA number:
Please provide your valid Driver's License number:*
Do you have transportation:*

YesNo
Do you have liability insurance on your vehicle?*

YesNo
Education History

Please fill out your education history below.
High School:
Name and Location
Diploma / Degree:
College / University:
Name and Location
Year Graduated:
Major:
Diploma / Degree:
College / University:
Name and Location
Year Graduated:
Major:
Diploma / Degree:
Other Training / Education:
in addition to your work history (below), what other experiences, skills or qualifications would especially fit you for work with our company?
Positions Applied For
1.
Wage or Salary desired?
2.
Wage or Salary desired?
Work History

Please enter your work history below.
May we contact your present employer?*

YesNo
Name of Most Recent Employer?
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Starting salary
Starting position
Date Left

MonthDayYear
Date
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Previous Employer 1
Name of Previous Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Starting salary
Starting position
Date Left

MonthDayYear
Date
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Previous Employer 2
Name of Previous Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Starting salary
Starting position
Date Left

MonthDayYear
Date
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Previous Employer 3
Name of Previous Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date Started

MonthDayYear
Date
Starting salary
Starting position
Date Left

MonthDayYear
Date
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Reference 1
Name of Reference*

First NameLast Name
Years Known*
Phone Number of Reference*
Please enter a valid phone number.
Reference 2
Name of Reference*

First NameLast Name
Years Known*
Phone Number of Reference*
Please enter a valid phone number.
Reference 3
Name of Reference*

First NameLast Name
Years Known*
Phone Number of Reference*
Please enter a valid phone number.
Final acknowledgements

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Company to make an investigation of any of the facts set forth in this application and release the Company from any liability.

I understand that employment at this Company is “at-will,” which means that either I or the Company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I understand that no supervisor, manager, or executive of the Company, other than the president in a signed writing has any authority to alter the foregoing.
Check this box if you agree and certify the above statements.*

Yes, I certify that the above is true
Date*

MonthDayYear
Date
Name*

First NameLast Name
Should be Empty:

ELITE APPLICATION FOR EMPLOYMENT

Education History

Positions Applied For

Work History

Previous Employer 1

Previous Employer 2

Previous Employer 3

Reference 1

Reference 2

Reference 3