Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date available to start *

MM

DD

YYYY

Are you a U.S. citizen? *

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever worked for this company before? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Did you graduate? *

Yes

No

Reference 1 *

First Name

Last Name

Reference 1's Phone Number *

(###)

###

####

Reference 2 *

First Name

Last Name

Reference 2's Phone Number *

(###)

###

####

Reference 3 *

First Name

Last Name

Reference 3's Phone Number *

(###)

###

####

Phone

(###)

###

####

May we contact your previous supervisor as a reference?

Yes

No

Availability *

We staff our homes with a series of three eight (8) hours shifts. Please review our shift below and circle all shifts you will be available to work on a regular basis. We require ALL employees to work weekends and as with all companies, an open availability will help fill your schedule to a full-time basis.

Day shift 8a-4p

Swing shift 4p-12a

Graveyard 12a-8a

Disclaimer *

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.