THE GOOD SAMARITAN HOME OF QUINCY
2130 Harrison Street
Quincy, IL 62301

APPLICATION FOR EMPLOYMENT
( Pre-employment Questionnaire ) ( An equal opportunity employer )


GENERAL INFORMATION

*First Name:  

*Last Name:

   Middle Initial :
Email Address:
*Street Address:
*City/Town:
*State:
*Zip:
*Home Telephone:   Work Telephone: Cell Number :
Are you 16 years or older ? : Yes   No
Are you either a U.S. citizen or an alien authorized to work in the United States ? : Yes   No

EMPLOYMENT DESIRED

*Position desired :   Date you can start : Salary desired : $
*Are you employed now ? Yes   No
If so, may we inquire of your present employer ?
*Ever applied to this company before ?   Yes   No When ? : Were you hired ? : Yes   No
Referred by :
Have you ever been convicted of a crime ? Yes   No
If yes, please explain :

EDUCATION
GRAMMAR / HIGHSCHOOL
Name and Location Years Attended
Did you graduate ?
Subjects studied
Yes   No
Yes   No
COLLEGE OR UNIVERSITY
Name and Location Years attended
Did you graduate ? Subjects studied
Yes   No
Yes   No

TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL
Name and Location Years attended
Did you graduate ? Subjects studied
Yes   No
Yes   No

Personal Skills and Activities
Subjects of special study or research and work or special skills :
 
Activities ( Civic, athletic, etc. ) Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members. :
 
U.S. Military or Naval Service :
Rank :
Present membership in National Guard or Reserves :

PROFESSIONAL EXPERIENCE
Employment History
PRESENT OR MOST RECENT POSITION
Name of Employer :
Address of Employer :
Employer's Telephone :
Business :


Former Position

Name of Employer :
Address of Employer :
Employer's Telephone :
Business :

Former Position
Name of Employer :  
Address of Employer :
Employer's Telephone :
Business :
WORK REFERENCES
Name Address
Business Telephone Number
PERSONAL REFERENCES
Name Address
Years Aquainted Telephone Number

WORK AVAILABILITY RECORD

:
Yes No
Yes No
Are you available to work holidays ? : Yes No
Yes No
Hours Available

PLEASE INDICATE DAYS AND HOURS YOU ARE AVAILABLE FOR WORK
Include AM and / PM
Be specific
Day From
To
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Do you have any responsibilities that would limit your availability ? : Yes No
If yes, please explain :

IF YOUR AVAILABILITY CHANGES, IT IS YOUR RESPONSIBILITY TO NOTIFY YOUR SUPERVISOR INDICATING THE CHANGES. SUCH CHANGES WILL BE EFFECTIVE, THEN, FOR ANY FUTURE EMPLOYMENT.

I UNDERSTAND THAT EMERGENCY CONDITIONS MAY REQUIRE ME TO TEMPORARILY WORK SHIFTS OTHER THAN THE ONE FOR WHICH I AM APPLYING AND AGREE TO SUCH SCHEDULING CHANGE AS DIRECTED BY MY DEPARTMENT HEAD OR ADMINISTRATOR OF THIS HOME.

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 THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES I LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.

 

PLEASE SIGN

*Today's date :
*Signature :

 

IN CASE OF AN EMERGENCY NOTIFY :
Name :
Address :
Phone Number :

 

*Required fields

REVIEW YOUR APPLICATION BEFORE SUBMITTING. YOU WILL NOT HAVE THE ABILITY TO CHANGE YOUR INFORMATION ONCE YOU SUBMIT.