Employment Form

APPLICANT INFORMATION

Date

Last Name *

first *

M.I.

Street Address *

Apartment/Unit # *

City *

State

ZIP code *

Phone *

Alternate Phone *

Email Address *

Soc Sec No. *

Date Available

Desired Salary

Position(s) Sought

Full Time

Part Time

On-Call

Are you legally eligible for employment in the United States?

Yes

No

Are you over the age of 18?

Yes

No

If you are offered a position, you will be required to provide documentation to verify eligibility.

Have you ever worked for Victory Staffing and Home Care?

Yes

No

If yes, when?

Have you ever been convicted of a crime other than a minor traffic offense?

Yes

No

If yes, explain

A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.

EDUCATION AND TRAINING

High School

Address (City, State)

From:

To:

Did you graduate?

Yes

No

Diploma?

Yes

No

GED?

Yes

No

College/Technical School

Address (City, State)

From:

To:

Did you graduate?

Yes

No

Degree/Major

Other School

Address (City, State)

From:

To:

Did you graduate?

Yes

No

Degree/Major

Professional License/Membership Type

State & Number

Expiration Date

Professional License/Membership Type

State & Number

Expiration Date

Please list any additional training, education or skills

PREVIOUS EMPLOYMENT

(Must show a minimum of 5 years employment history.)

Please list most recent employment first, including military experience.

Company

Address

Phone

Position Held

Dates of Employment (mo/yr)

From:

To:

Immediate Supervisor

Department

FT

PT

Hrs/wk

Beg. Salary

End Salary

Duties

Reason for leaving

May we contact this employer?

Yes

No

Company

Address

Phone

Position Held

Dates of Employment (mo/yr)

From:

To:

Immediate Supervisor

Department

FT

PT

Hrs/wk

Beg. Salary

End Salary

Duties

Reason for leaving

May we contact this employer?

Yes

No

Company

Address

Phone

Position Held

Dates of Employment (mo/yr)

From:

To:

Immediate Supervisor

Department

FT

PT

Hrs/wk

Beg. Salary

End Salary

Duties

Reason for leaving

May we contact this employer?

Yes

No

Company

Address

Phone

Position Held

Dates of Employment (mo/yr)

From:

To:

Immediate Supervisor

Department

FT

PT

Hrs/wk

Beg. Salary

End Salary

Duties

Reason for leaving

May we contact this employer?

Yes

No

Please explain any gaps in your employment history

Have you ever been discharged or asked to resign from a position?

Yes

No

If yes, please explain

Please describe any additional relevant work experience

Yes

No

REFERENCES

Name

Relationship

Company

Phone

Email Address

Years Known

Name

Relationship

Company

Phone

Email Address

Years Known

Name

Relationship

Company

Phone

Email Address

Years Known

APPLICANT CERTIFICATION AND AGREEMENT

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Victory Staffing & Home Care, Inc. to verify their accuracy and to obtain reference information on my work performance. I hereby release Victory Staffing & Home Care, Inc. from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Victory Staffing & Home Care, Inc. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

Applicant Signature *

Date: