Employee Application | Caring Hands - Kotes Clinics Website Theme

Personal Information

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email

Employment Desired

Work Experience

(List below the last four employers, starting with current employment first)

Experience #1

Employment start and end date

Job Title

Duties

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Salary

Reason for leaving

Experience #2

Employment start and end date

Employment start and end date (copy)

Job Title

Duties

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Salary

Reason for leaving

Experience #3

Employment start and end date

Job Title

Duties

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Salary

Reason for leaving

Volunteer Work

Experience #1

Volunteer start and end date

Name of Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Role

List of Duties

Experience #2

Volunteer start and end date

Name of Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Role

List of Duties

Experience #3

Volunteer start and end date

Name of Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Role

List Duties

MILITARY BACKGROUND

(Leave blank if not applicable)

Dropdown Items

Type of discharge?

EMPLOYMENT/PROFESSIONAL REFERENCES

(Give the names below of three persons not related to you, whom you have a professional working relationship with and have known for at least one year)

Reference #1

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional Relationship

Years known

Reference #2

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional Relationship

Years known

Reference #3

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Professional Relationship

Years known

Education

Level of Education

Graduate School
College
Trade or Business School
High School

Education #1

Name of School

Years Attended

Course of study

Location of School

Did you graduate?

Yes
No

Education #2

Name of School

Years Attended

Course of study

Location of School

Did you graduate?

Yes
No

Professional Information

Professional Licensure(s):

Effective Date(s):

Certification(s):

Effective Date(s):

Out of State License(s):

UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQURE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILY OR A MISDEAMENOR AND SUBJECT TO A FINE NOT TO EXCEED $100.”AUTHORIZATION:“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 APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE BHC FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.”*REGULATIONS REQUIRE THAT YOU REPORT ANY AND ALL CRIMINAL HISTORY INCLUDING CONVICTIONS, PBJ, NOT CRIMINALLY RESPONSIBLE AND PENDING CHARGES. THE DETERMINATION OF EMPLOYMENT WILL BE MADE BASED ON YOUR QUALIFICATIONS AND PARTIALLY BASED ON ANY CRIMINAL HISTORY YOU MIGHT HAVE. HOWEVER, WE DO NOT RESTRICT EMPLOYMENT DUE TO A CRIMINAL HISTORY. A DECISION TO PROHIBIT EMPLOYMENT WILL BE BASED ON THE SEVERITY OF THE OFFENSE, HOW LONG AGO THE OFFENSE OCCURRED, AND ANY POSSIBLE IMPLICATIONS TO THE JOB FOR WHICH YOU ARE APPLYING. NONETHELESS, IF HIRED, FAILURE TO REPORT PAST OR FUTURE CRIMINAL ACTIVITY CAN RESULT IN TERMINATION OF YOUR EMPLOYMENT. IF HIRED, YOU WILL BE REQURED TO ALLOW US TO CHECK YOUR FEDERAL AND STATE CRIMINAL HISTORY.I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF BHC HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FORGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED BHC REPRESENTATIVE.”

Signature

Clear Signature

Date

CRIMINAL BACKGROUND

(You must report all criminal convictions, probation before judgement dispositions, not criminally responsible dispositions, and/or pending charges without a final disposition)

Offense/Charge

Disposition

Date of Disposition

Personal Information

Employment Desired

Work Experience

Experience #1

Experience #2

Experience #3

Volunteer Work

Experience #1

Experience #2

Experience #3

MILITARY BACKGROUND

EMPLOYMENT/PROFESSIONAL REFERENCES

Reference #1

Reference #2

Reference #3

Education

Education #1

Education #2

Professional Information

CRIMINAL BACKGROUND

Service Areas Covered:

Presets Color