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Job Application Position......
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Position
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Applicant Information
Full Name:
*
First
Middle
Last
Date Of Birth:
*
Phone Number
*
Address:
*
Address Line 1
Address Line 2
City
State
Zip Code
Email:
*
Social Security #:
Position Applied For:
Days Available:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Shift Available:
First Shift: 8AM - 4PM
Second Shift: 4pm - 12 AM
Third Shift: 12AM - 8 AM
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S?
*
Yes
No
Do you have a driver's license?
*
Yes
No
If yes, since when?
Have you ever been convicted of a felony?
*
Yes
No
If yes, explain:
*
Have you ever had a substantiated case brought against you by Child and/or Adult Protective Service?
*
Yes
No
If yes, explain:
*
Education
Certificate:
List your certificates in the field above
High School:
Address:
High School Start Date:
High School End Date:
Did you graduate?
*
Yes
No
Diploma:
College Name:
Address:
From:
To:
Did you graduate?
Yes
No
Degree:
References
Please list three professional references
Full Name:
*
First
Middle
Last
Relationship:
Company:
Phone:
*
Email address:
Full Name:
*
First
Middle
Last
Relationship:
Company:
Phone:
*
Email address:
Full Name:
*
First
Middle
Last
Relationship:
Company:
Phone:
*
Address:
Previous Employment
Company:
*
Phone:
*
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company:
*
Phone:
*
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Military Service
Branch:
From
To
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in my release. If hired; (1) I agree to follow all rules and regulations of Coastal Community Care, LLC as they develop and change. (2) I authorize Building Bridge Adults Services LLC to conduct investigation on me; my background check and my performance, and I understand that the results will become a part of my employment record.
Signature:
*
Sign with your Full Name
Submit
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