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EMPLOYMENT APPLICATION: JEAN WHATLEY'S ALLIANCE

(Please complete the entire application)

Employer Information
Employer: Jean Whatley's Alliance Home Health Care
Location: Papillion, Nebraska 68127
Position: Personal Care Assistant

It is the policy of Jean Whatley's Alliance to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability, or veteran status.

Applicant Information

Full Name

First

Last

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information

Daytime Phone

Mobile Phone

(If different from above)

Email Address

Position Applied For

Desired Salary/Per $

Are you at Least 18 years old?

Are you willing to work any shift, including nights and weekends?

If you are offered employment, when would you be available to begin work?

If hired, are you able to submit proof that you are legally eligible for employment in the United States?

Education

High School/GED

Did you recieve a Diploma?

Employment History

List your current or most recent employment first. Please list all jobs held, beggining with the most recent.

Employer: 1

Reason any (Month/Year)

Employer Name:

Supervisor Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Duties:

Reason for Leaving

Dates of Employment (Month/Year)

Employer : 2

Employer Name:

Supervisor Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Duties:

Reason for Leaving

Dates of Employment (Month/Year)

Employer: 3

Employer Name:

Supervisor Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Duties:

Reason for Leaving

Dates of Employment (Month/Year)

Disclaimer

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Jean Whatley's Alliance to contact former employers regarding my employment. I authorize my former employers to communicate information fully and freely regarding my previous employment and attendance.

If employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Executive Director, the employment relationship will be "at will". In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reason of my choice. Similarly, my employer will have the right. Moreover, no agent representative, or employee of Jean Whatley's Alliance, except in specific written contract of employment signed on behalf of the organization by it's Executive Director, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

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Time

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EMPLOYMENT APPLICATION: JEAN WHATLEY'S ALLIANCE

(Please complete the entire application)

Applicant Information

Contact Information

Education

Employment History

Employer: 1

Employer : 2

Employer: 3

Disclaimer

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