APPLICATION FOR EMPLOYMENT

EDUCATION:

High School *

School Name *

Location of School *

Course of Study *

Years Attended *

Vo-Tech or Trade

School Name

Location of School

Course of Study

Years Attended

Other

School Name

Location of School

Course of Study

Years Attended

College

School Name

Location of School

Course of Study

Years Attended

Employment History

Company Name

Telephone

Address

Currently Working

From

City

State

Zip Code

Current Pay

Job Title and Describe your work

Reason for leaving

Company Name

Telephone

Address

Dates of Employment

From

City

State

Zip Code:

Current Pay:

Job Title and Describe your work:

Reason for leaving:

Company Name

Telephone

Address

Dates of Employment

From:

To:

City

State

Zip Code:

Current Pay:

Job Title and Describe your work:

Reason for leaving:

APPLICATION FOR EMPLOYMENT

Are you currently employed? *

Yes

Was your last name different from your present name during the above listed jobs?

Yes

If yes, what was your name?

Has your Driver’s License been suspended or revoked?

Yes

Ending hourly pay rate *

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance

Name *

Telephone *

Fax

Address

Name

Telephone

Fax

Address

Name

Telephone

Fax

Address

Have you ever been convicted of a crime in the past, barring employment in a Home Care and community support Agency? *

Yes

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full

What do you enjoy doing or are your hobbies?

What are a few things you enjoy getting as a small gift (be specific)?

Application for Employment

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

SIGNATURE *

DATE *

KEY MINDS INC. BACKGROUND CHECK CONSENT FORM

understand that a criminal check is being conducted with respect to my employment application:

1. If the criminal check shows that I have been convicted of any of the felonies listed below under Part I, I will not be offered employment.

2. If the criminal check shows that I have been convicted of any of the felonies listed below under Part II in the past ten years, I will not be offered employment

3. I understand also that searches of various website will be undertaken, to include Nurse’ Registries, National Sex Offender Registry and the OIG’s exclusion list. If I appear in any of these registries as being unsuitable for hire, I will not be offered employment

PART I

DISQUALIFYING OFFENSES

Rape as defined in IC 35-42-41

Criminal Deviate Conduct as defined in IC 35-42-4-2 (includes crimes of violence) Exploitation of an endangered children/adult as defined in IC 35-46-1-12 Failure to report battery, neglect, or exploitation of an endangered children/adult as defined in IC 35-46-1-13.

A felony that is substantially equivalent to a felony listed above

PART II

DISQUALIFYING UNLESS TEN (10) YEARS HAVE PASSED FROM THE DATE OF CONVICTION

Theft as defined in IC 35-43-4)

A felony that is substantially equivalent to a felony listed above

Email *

Other Name Used *

Date of Birth *

Soc *

First Name *

Middle Initial

Last Name *

SIGNATURE *

DATE *