For Employers Form

* = Required Information

Position You Are Applying For

Desired Salary

Date Available for Work

PERSONAL INFORMATION

Last Name *

First Name *

Middle

Address

City

State

Zip

Home Phone *

Cell Phone *

Email Address *

Social Security Number

Date of Birth

Are you a U.S. Citizen?

Yes

Have you ever been convicted of a felony?

Yes

If selected for employment are you willing to submit to a pre-employment drug screening test?

Yes

EDUCATION

School Name

Location

Years Attended

Degree Received

Major

School Name

Location

Years Attended

Degree Received

Major

School Name

Location

Years Attended

Degree Received

Major

Other training, certifications or licenses held:

EMPLOYMENT

Employer

Dates Employed

Work Phone

Pay Rate:

Address

City

State

Zip

Position

Duties Performed

Supervisors Name and Title

Reason for Leaving

May we contact them

Yes

REFERENCES

Name

Title

Company

Phone

Name

Title

Company

Phone

Name

Title

Company

Phone

Acknowledgement and Authorization

I certify that all answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

Signature of Applicant *

Date

Professional Employment Reference Form
APPLICANT: Please fill out shaded areas only.

Your name

Position(s) applying for

Reference type (please choose one)

Supervisor	DON
Manager	Other/Professional

Other/Professional

Reference Name

Reference Company

Reference Title

Reference Phone #

I hereby authorize you to release any and all information that pertains to my job performance.

Applicant Signature

Professional Employment Reference Form
APPLICANT: Please fill out shaded areas only.

Your name

Position(s) applying for

Reference type (please choose one)
Supervisor DON
Manager Other/Professional

Other/Professional

Reference Name

Reference Company

Reference Title

Reference Phone #

I hereby authorize you to release any and all information that pertains to my job performance.

Applicant Signature

HBV VACCINE/WAIVER FORM

Employee Name

Dates of Hire

Social Security Number

I understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) Infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.

I have been advised of my rights to accept or decline the HBV Vaccine.

HBV (Hepatitis B Virus) has been fully explained to me.

I choose to waive my rights to receive the HBV Vaccine

I choose to receive the HBV Vaccine and I understand that the vaccine is given in a 3-part series.

Series #1 Date

Series #2 Date

Series #3 Date

Employee Signature *

Date

Agency Rep. Signature

Date

Attachments

COVID Vaccination Card*

Influenza Vaccination

LICNS License Card & Online Verification*

National Provider Identifier Number

2 Professional References*

Resume*