Application For Employment - Extension Home Health Services Page 2
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3Extension Home Health Services
EMPLOYMENT APPLICATION
PAGE 2
Date
Name and address of
Reason for
Month and Year
employer
Salary
Job
Leaving
From
To
From
To
From
To
References: Give the names of three persons not related to you to whom you have known at least 1 year
Name
Address
Phone
Yrs acquainted
List any foreign language(s) and check the box that best describes your skill level.
Language
Read and write
Read and speak
Speak only
In case of
Emergency notify
Name
Address
Relationship
Phone
Conditions of Employment – please read carefully
INITIAL
Reporting to work with impaired abilities; or the possession, consumption or
distribution of drugs or alcohol on company premises and/or worksites, shall be grounds
for disciplinary action, including discharge. A condition of employment includes
willingness on the part of the applicant or employee to agree to physical examination,
polygraph and/or substance testing, if required by the company. We are committed to
operating a drug free workplace. Violations of our drug and alcohol policy will result in
dismissal.
_____ It is understood and agreed upon that any misrepresentation by me in this
application will be sufficient cause for cancellation of this application and/or separation
from the employer’s service, if I have been employed. Furthermore, I understand that
just as I am free to resign anytime, the Employer reserves the right to terminate my
employment at any time, with or without cause and without prior notice. I understand
that no representative of the Employer has the authority to make any assurances to the
contrary.
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