EMPLOYMENT APPLICATION FORM

High School Name and Address

Dates Attended:

Diploma Received?

Area of Study

Colleges/ Training Schools

Dates Attended:

Diploma Received?

Area of Study

Professional trainings/qualifications with dates and levels obtained

Present or most recent employer and address:

Dates (month/year)

Position Held and Duties:

Reason for leaving

Starting Salary:

Ending Salary:

May we contact this employer? Yes No

If no, please indicate reason.

Give details of your work history with the most recent listed first:

ONE

Employer and address:

Dates (month/year)

Position Held and Duties:

Reason for leaving

Starting Salary:

Ending Salary:

May we contact this employer? Yes No

If no, please indicate reason.

Give details of your work history with the most recent listed first:

TWO

Employer and address:

Dates (month/year)

Position Held and Duties:

Reason for leaving

Starting Salary:

Ending Salary:

May we contact this employer? Yes No

If no, please indicate reason.

Please indicate all relevant experience, skills, and work history that relate to the job description of which you have applied. Please print clearly. All illegible entries will not be considered.

(attach additional sheets if necessary)

What absences due to illness have you had from work for the last two years?

Do you have any illness that will prevent you from performing the duties of the position for which you have applied? Yes No

If yes, please indicate:

Can you lift a weight of seventy pounds? Yes No

Please list three-character references whom we may contact.

Name

Relationship

Years of Affiliation

Telephone Number

By signing below, I , on the date of

hereby certify that all information included in the above application is true and valid to the best of my knowledge. I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery.

READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT.

I agree that except at the request and for the benefit of Beyond Care Staffing & Health Services, I will not disclose to anyone or use for my own purposes any of the confidential or proprietary information, either during or after my employment. I understand and agree that Beyond Care Staffing & Health Services bidding, costs, pricing and marketing information and techniques, customer names and information, and employee names and information are confidential and proprietary to Beyond Care Staffing & Health Services.

I certify that this application contains no willful misrepresentation or falsifications and that the information given by me is true and complete to the best of my knowledge and belief. I authorize Beyond Care Staffing & Health Services to contact all sources to verify the information on this application. I understand that any falsification, misrepresentation, or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge.

I understand that this application is not a contract of employment.

I authorize and request my former employers, references, and educational institutions which have information about me, to give Beyond Care Staffing & Health Services any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorize and request federal, state, and local governmental agencies to release to Beyond Care Staffing & Health Services any information requested concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.

I acknowledge that I have read the company policy statement concerning conflict of interest, and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy.