SOUTHERN CRESCENT HOME CARE

Date *

MM

DD

YYYY

Legal Names *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you 18 years of age or older? *

YES

NO

Are you legally eligible for employment in this country? *

documentation proving identity and eligibility to work in the U.S. will be required upon employment.

YES

NO

Can you perform the essential job-related functions of the position for which you have applied for with or without reasonable accommodations? *

YES

NO

Have you ever been convicted of a felony? *

YES

NO

Have you ever been employed at SCHC? *

YES

NO

Friends or relatives employed with SCHC? *

YES

NO

Have you signed a non-compete agreement or contract with your present employer? *

YES

NO

Do you have a valid Driver's License? *

YES

NO

Reliable means of transportation? *

YES

NO

Date available to start

MM

DD

YYYY

Willing to work overtime? *

YES

NO

Are you able to meet the attendance requirements of the position? *

YES

NO

Have you ever been dismissed or forced to resign from employment? *

YES

NO

May we contact your past/present employers? *

YES

NO

School Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

College Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Trade, Business, Craft School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SIGNATURE OF APPLICANT *

I understand than SCHC is committed to providing a healthful, safe, efficient work environment that is free from substance abuse. The company believes that drug abuse is inconsistent with these goals. Therefore, it is the policy and practice of SCHC to randomly drug test prior to employment. If any levels of drugs are found in the applicant's system, offer of employment will be rescinded. Accordingly, refusal to submit such screening will foreclose any further hiring action with the candidate. I am aware of SCHC's possible request for pre-employment drug screening and I agree to test prior to commencing employment. I release SCHC, its officers, managers, and representatives from any liability for the conducting of pre-employment drug testing and for the use of and/or reliance upon the results of the drug test in reaching a decision related to my employment. I also understand that I may be required to take drug screens during the course of my employment.

First Name

Last Name

DATE

MM

DD

YYYY

E-SIGNATURE *

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

First Name

Last Name

DATE SIGNED *

MM

DD

YYYY