Job Application

Fields marked with an asterisk (*) must be filled out before submitting.


Facility you are applying to: *
Date of Application *

Personal Information

Full Name *
Email Address
Current Address (Street, City, State) *
Telephone *

Position Desired

Position Applying for: *
When can you start? *
Can you work any shift? * Yes
If no, what shift can you work?
Are you under 18 years of age? * Yes
If yes, do you have a work permit?
Have you ever been convicted of a crime? * Yes
If yes, please explain the offense, the date and the place. Conviction of a criminal offense will not necessarily prevent your employment.
Have you ever applied to this company before? * Yes
If yes, when?
Have you ever worked for this company before? Yes
If yes, when?
Who was your supervisor?
Reason for leaving
Please list any friends or relatives (Name, Relationship) currently working at Elder Outreach:
Can you perform the functions of the job for which you are applying with or without reasonable accommodations? Yes
If no, please explain


Please Select the highest level achieved: * High School
Graduate Degree
If other, please specify
Professional License or Certificate (Type, State Issued In, Expiration Date)

Employment Record

Please list most recent employer *
Date you started *
Date of your last day *
Job Title *
Supervisor *
Work/Duties Performed *
Hourly Rate/Salary *
Reason for Leaving *
You may include a filled out print application or CV.

I understand that any employment by this community will be on a three (3) month basis. If employed by Elder Outreach, I agree to abide by its rules and regulations. I understand that this community will check the references provided in this application, including former employers, supervisors and schools. I give authorization to these individuals, companies, and schools to furnish information and I release from all liability or responsibility this community, all persons, companies or corporations releasing or using this information.

I understand that I will be required to submit other background related information so that various background checks can be conducted. I may also be required at any time to submit to employment physical examinations, drug tests, health screes as per community policy. I give authorization to the community to have access to this information.

I understand that I must produce a driver’s license, social security card or other documents proving my identity and right to work in the United States.

I certify that all information disclosed on this application is true and accurate. I understand that my employment is at will, and either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement of omission of fact appearing on this application.

We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status.

Do you understand and agree? * Yes, I understand.
Electronic Signature (Enter Full Name, Date) *