Personal Information:
Contractor Name______________________________________ SS# ____________________Tax ID# _________________________ CDL #_____________
Present Address
___________________________________City___________________Zip_____
Phone( _ _ _ ) _ _ _-_ _ _ _ Are you 18 years or older ? YES NO
D.O.B.___________________________
Employment Desired:
Position___________________ Date you can start
_______________________________ Full time_____ Part time_____
Are you employed or providing services on contract now? YES_____ NO_____
May we inquire of your present employer/Clients? YES____ NO___
Provides Services to/Supervisor’s Name________________________________
Phone ( _ _ _ ) _ _ _ - _ _ _ _
Education:
High School ______________________________ # of years_______ Did you
Graduate?___________
College__________________________________ # of years _______ Did you
Graduate?___________
Trade School, etc.__________________________ # of years _______ Did you
Graduate?___________
Personal References: Please list 3 non-relatives whom you have known for at
least 2 years.
NAME PHONE RELATIONSHIP YEARS KNOWN
In case of Emergency , address of nearest relative:
Name/Address______________________________________ Phone ( _ _ _ ) _
_ _ - _ _ _ _ Cell ( _ _ _ ) _ _ _ - _ _ _ _
Previous / Current Contract Clients, or Employment:
Please list the past (3) (Most recent first)
Client / Company name Address_______________________________
Phone_________________________________________
Date Start______________________________Date End___________________
Last Position______________________
Pay rate/Start___________Pay rate/End__________Reason for
Leaving______________________________________
Supervisor’s Name________________________________ Phone ( _ _ _ ) _ _ _
- _ _ _ _ Cell. ( _ _ _ ) _ _ _ - _ _ _ _
Duties Required to
Perform__________________________________________________________
_________________________________
________________________________________________________________
_________________________________
Client / Company name Address_______________________________________Phone_____________
____________________
Date Start__________________ Date End___________________ Last
Position______________________
Pay rate/Start_________Pay rate/End_________________Reason for
Leaving_________________________________
Supervisor’s Name___________________________________Phone ( _ _ _ ) _
_ _ - _ _ _ _ Cell ( _ _ _ ) _ _ _ - _ _ _ _
Duties Required to
Perform__________________________________________________________
_________________________________
________________________________________________________________
_________________________________
Client / Company name Address_______________________________________Phone_____________
____________________
Date Start__________________ Date End___________________ Last
Position______________________
Pay rate/Start_________Pay rate/End_________________Reason for
Leaving_________________________________
Supervisor’s Name___________________________________Phone ( _ _ _ ) _
_ _ - _ _ _ _ Cell ( _ _ _ ) _ _ _ - _ _ _ _
What days or evenings are you available to work?(below)
________________________________________
What hours are you available to work? (enter below)
Are there any activities that would prevent you from working certain days and or hours? (enter below)
Monday Tuesday Wednesday Thursday Friday Sunday
AM Include DMV Report |
Why do you feel you would be a a good service provider for ACIMA
WELLNESS2U? _________________________________________________
What do you consider to be your outstanding qualities?
____________________________________________________
What do you consider to be your worst qualities?
__________________________________________________________
What kind of circumstances makes you nervous or tense?
__________________________________________________
Will it affect your work behavior? ________________________________________________________________
_______
Would you take a DRUG TEST ?_________ Since handling cash, would you
take a Polygraph (Lie detector Test?)_______
Have you ever been convicted of a felony or misdemeanor? YES____ NO___
(if YES,
explain)__________________________________________________________
List your favorite hobbies/interest:
1.___________________2.____________________ 3.____________________
List any special skills or Specialized Services:____________________________ ________________________________________________________________
_____________________
Applicant represents that all information given on this application is true and
correct. Applicant hereby authorizes
verification of all references and facts, including but not limited to current and
previous employers, and personal
references. Applicant hereby authorizes
owner/agent/manager to obtain, Company, Personal Credit Reports, background
reports. Applicant understands we contract service providers.
Applicant hereby waives any claim
providing or obtaining said verification or additional information.
and releases from liability any person
facts contained in this application are true and complete to the best of my
knowledge and understand that,
application shall be grounds for dismissal.
if employed, falsified statements of this
Applicant
understands
that incomplete or incorrect information provided in the application
may cause a delay in processing which may result in denial of employment.
I certify that the
_____________________________ ________________________________
Applicant Signature