Employment CURRENT JOBS Employment Application In connection with, and for the duration of employment, including contract for services with Markesan Resident Home, I understand that investigative background inquiries are conducted into criminal, driving and other reporting. This reporting will include information as to: character, work habits and performance along with reasons for termination from previous employers. Further, I understand that, if I am offered a position, Markesan Resident Home will be requesting information from various Federal, State and other agencies that maintain records concerning any past activities relating but not limited to: driving, criminal, civil and other reports. I authorize any party or agency contracted by Markesan Resident Home to furnish the above mentioned information. 1 Applicant Information2 Education, Training, and Certifications3 Employment History4 References & Signature Applicant InformationName First Last AddressCity/State/ZipPhoneEmailDriver's License #StateElectronic SignatureDatePosition Applying ForDate Available Education, Training, and CertificationsHigh SchoolName and Address of SchoolCourse TakenDid you graduate? Yes No Date of Diploma, Degree, or CertificateCollegeName and Address of SchoolCourse TakenDid you graduate? Yes No Date of Diploma, Degree, or CertificateOther Classes/TrainingProfessional Organization Memberships, honors received, volunteer or community service or other qualifications related to the position for which you are applyingProfessional Licenses and/or CertificationsTypeOrganization of State IssuedDate IssuedNumberTypeOrganization of State IssuedDate IssuedNumber Employment HistoryList current (most recent) employer first and all others in reverse chronological order.Company NameStart DateEnd DateAddressPhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name/TitleJob Description and ResponsibilitiesMay we contact for reference? Yes No Company NameStart DateEnd DateAddressPhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name/TitleJob Description and ResponsibilitiesMay we contact for reference? Yes No Company NameStart DateEnd DateAddressPhoneStarting SalaryEnding SalaryPosition TitleImmediate Supervisor's Name/TitleJob Description and ResponsibilitiesMay we contact for reference? Yes No References & SignatureList three references who are not relatives or former employees.Name & RelationshipTitleCompany Name & AddressPhone NumberName & RelationshipTitleCompany Name & AddressPhone NumberName & RelationshipTitleCompany Name & AddressPhone NumberHave you ever been convicted of a crime? Yes No If so, what?Are you currently under investigation for resident abuse, neglect or misappropriation? Yes No Markesan Resident Home does not discriminate on the basis of race, color, sex, citizenship, national origin, ancestry, Veteran Status or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give Markesan Resident Home the right to conduct a thorough investigation of my past employment and activities, agree to cooperate in such investigations and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take any physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent upon passing the pre-employment process. If employed, I will be required to complete an Employment Verification Form (I-9) within three days of hire to show satisfactory evidence of identity and eligibility for employment. Applicant's SignatureDateCAPTCHA
