Employment Application

Note: Fields marked with a * require an answer. Please use "N/A" for "not applicable" if necessary. Applicants may be required to complete and sign a paper application for employment upon interview. It is important that you select the correct position to insure your application is processed appropriately.
Attach Resume:
Email:
Position Applied for:
Region Applied for:

Applicant Information

*First Name: *Last Name: MI:
*Address: Apartment/Unit #
*City *State
*Zip:
*Phone: Referred By:
Date Available:

 Salary Expected:
*Social: I can work:  Weekends    Evening    Night
U.S. Citizen:  Yes    No If not, are you authorized to work in the U.S.?:  Yes     No
Languages Spoken:   Driver's License No:  State: 
*Have you ever worked for this company?:  Yes     No If yes, when?:  to   (mm/dd/yyyy)
*Have you ever been convicted of a felony?
(By company policy some misdemeanors may bar employment) 		 Yes     No If yes, explain briefly:

Education

High School:   Address:
Graduate:    Yes     No   Degree:
College:   Address:
Graduate:    Yes     No   Degree:
Other:   Address:
Graduate:    Yes     No   Degree:

References

Please list three references not related to you, whom you have known at least one year.
Name: Occupation:
Company: Day Phone Numbers:
Address:
Name: Occupation:
Company: Day Phone Numbers:
Address:
Name: Occupation:
Company: Day Phone Numbers:
Address:

Previous Employment

Please enter at least last 3 employers Employer 1
Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
(mm/dd/yyyy)		 End Date:
(mm/dd/yyyy)
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No
Employer 2
Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
(mm/dd/yyyy)		 End Date:
(mm/dd/yyyy)
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No
Employer 3
Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
(mm/dd/yyyy)		 End Date:
(mm/dd/yyyy)
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No

Military Service

Start Date:
(mm/dd/yyyy)		 End Date:
(mm/dd/yyyy)
Branch: Rank at Discharge:
Type of Discharge: If other than honorable, explain:

Additional Questions

Tell me about yourself: Why are you interested in this position?:
Tell me about your previous work experience that relates to this position: How did you hear about Harmony Living Centers?:
Name 5 things clients could do for entertainment in this area: 1.
2.
3.
4.
5.
 What would you do if a client was physically aggressive towards you?:

Applicant's Statement

Notification and Agreement

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand
that false or misleading information in my application or interview may result in my release.

I authorized investigation of all statements contained herein and the references and employers listed above may have, personal or
otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also, understand and agree that no representative of the company has any authority to enter into any agreement for employment
for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an
authorized company representative. I understand that if I'm offered employment, I will be required to Sign and Date this printed form.

Signature Date