Phoenix House & Well

Application for Employment - Download the PDF version of this form
             
Personal Information      
           
Name: Date:
Current Address (Street Address): Home Phone #:
City, State, Zip: Easiest # to reach you:
Previous Address (Street Address): Social Security Number:
City, State, Zip:      
           
       
Are you prevented from being lawfully employed in the United States?

Yes No

    
Are you 18 years of age or older? Yes No    
For reference purposes, have you worked or attended school under a former name? Yes No    
If yes, please list former name:    
Have you ever applied here before? Yes No    
If yes, when?    
Have you ever been employed here before? Yes No    
If yes, when?    
Do you have reliable transportation means to and from work? Yes No    
Are you able to perform the essential functions of the job you are applying for? Yes No    
If no, what accommodation would assist you?    
Why would you like to work here?      
 

 
           
Education, Training & Special Skills      
           
Type of School    

Did you graduate?

 Grade Average Major/Minor
High School: Name: Yes No
Location:
           
Trade School or Junior College: Name: Yes No
Location:
           
College / University: Name: Yes No
Location:
           
Graduate School: Name: Yes No
Location:
           
Military or Other: Name: Yes No
Location:
           
Professional Licenses or Certifications:

           
Employment Preference      
           
Position Desired: Earnings Desired:
           
Days/Nights Available to Work (please note hours) Sun Mon Tue Wed Thur Fri Sat
  AM
  PM
  EVE
           
Employment History      
List the 3 most previous places of employment.    
           
Employer 1:   Phone Number:
Address:   Start Date (month/year):
Address (line 2): End Date (month/year):
Supervisor Name: Starting Wage:
Supervisor Phone Number: Ending Wage:
           
May we contact this employer? Yes No Last Bonus or Incentive:
           
Title or Position:  
Duties/Responsibilities:  
           
Reason for Leaving:  
           
           
Employer 2:   Phone Number:
Address:   Start Date (month/year):
Address (line 2): End Date (month/year):
Supervisor Name: Starting Wage:
Supervisor Phone Number: Ending Wage:
           
May we contact this employer? Yes No Last Bonus or Incentive:
           
Title or Position:  
Duties/Responsibilities::  
           
Reason for Leaving:  
           
           
Employer 3:   Phone Number:
Address:   Start Date (month/year):
Address (line 2): End Date (month/year):
Supervisor Name: Starting Wage:
Supervisor Phone Number: Ending Wage:
           
May we contact this employer? Yes No Last Bonus or Incentive:
           
Title or Position:  
Duties/Responsibilities:  
           
Reason for Leaving:  
           
           
References          
Please list references, do not include family members or people who you live with  
           
Name:        
Address:        
Phone Number:      
Occupation:        
Years Acquainted:      
           
Name:        
Address:        
Phone Number:      
Occupation:        
Years Acquainted:      
           
Name:        
Address:        
Phone Number:      
Occupation:        
Years Acquainted:      
           
Certification      
  I certify the information contained in this application is true and complete to the best of my knowledge. Any misrepresentation or omissions of any fact in my application can be justification for refusal of employment or if employed grounds for termination.

I authorize the company to investigate all statements contained in this application and release all parties from any liability for any damage that may result from furnishing same to you.

I understand that my employment may be terminated with or without cause or notice, at any time, at the option of either the Company or myself.

  
           
Type name:    
           
Type date:    
           
Enter email address:    
           
           
       
           

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