APPLICATION FOR EMPLOYMENT

All prospective employees will receive consideration without discrimination because of race, color, sex, age, natural origin, or handicap. All information provided herein will be kept confidential. A pre-employment health screening is required prior to employment, which may include a DRUG SCREEN. In compliance with House Bill 2100 which requires all licensed facilities to offer only temporary employment to non-licensed new personnel, until a criminal check can be completed by the Oklahoma State Bureau of Investigation. I, by signing this application give permission to perform to O.S.B.I. check.

Personal

Last Name
First Name
Middle Name
Email
Date
Street Address
City
State
Zip
Home Phone
Business Phone
Social Security Number
Emergency Contact (person not living with you)
Emergency Contact Phone
When will you be available for work?	month day year
How many hours a week are you available for work?	Minimum Maximum
Are you legally eligible for employment in the United State?	Yes No
How did you learn about our organization?
Position applying for:	Adm/Clerical Home Health Aide Housekeeper RN LPN Physical Therapist Occ. Therapist Sitter Speech Therapist PTA MSW Chaplain Volunteer COTA Other If "Other", please specify:

Employment History (Optional for Volunteers)

List the last 10 years of your employment history, starting with the most recent employer.

1. Company Name
Telephone
Address:
Date of Employment	to
Name of supervisor:
Starting Pay
Ending
Job title and describe your work:
Reason for leaving:
2. Company Name
Telephone
Address:
Date of Employment	to
Name of supervisor:
Starting Pay
Ending
Job title and describe your work:
Reason for leaving:
3. Company Name
Telephone
Address:
Date of Employment	to
Name of supervisor:
Starting Pay
Ending
Job title and describe your work:
Reason for leaving:
May we contact your present employer?	Yes No
Do you have reliable transportation if required?	Yes No

Professional And/Or Personal References

Persons who can inform us about job performance:

1. Name
Telephone
Address:
2. Name
Telephone
Address:
3. Name
Telephone
Address:

General

Have you been convicted of a crime in the last 10 years, excluding misdemeanors and summary offenses, which have not been annulled, expunged, or sealed by a court? Yes No

Convictions will not necessarily disqualify an applicant from employment.

If yes, describe in full:

Are you capable of performing the job duties set forth in the job description? Yes No

EDUCATION

Name and Location of school	Years Attended	Did You Graduate	Major course of study
High School
College
Trade or Business

Credentials/Specialized Skill & Qualifications/Equipment Operated

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualifications acquired from employment or other experience

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 hereby give my full permission for CHOICE to contact and fully discuss my background and history with all persons and entities listed, and to give CHOICE 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 liabilities for any damage that may result in furnishing same to CHOICE.

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.

The 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.

Date:
Signature of Applicant:

Confidential Reference Inquiry

Employee/Applicant Name:
Job Title:
Social Security Number:
Date of Hire:
Date of Discharge:
Reason for Leaving:
Applicant Eligible for Rehire: Yes No
Name of Person Giving Reference:
Phone Reference Evaluation:
Signature/Date: