CAREER – Trinity Life Care Inc.

Employment Application Form

Thank you for your interest in Trinity LifeCare Inc. If you are interested in working with us, complete the form below and press the “Submit” button. One of our staff will contact you to give you specific information on employment..

Referred by (please print the staff name here) *

Position(s) of interest

Date

First Name

Middle Name

Last Name

Present Street Address

Apt. Number

Cell Phone Number

City

State

Zip Code

Home Phone Number

Email Address

Work/Other Phone Number

Are you 18 years of age or older?

YESNO

Are you authorized to work in the United States of America?

YESNO

Do you have a valid U.S. driver’s license?

YESNO

Driver’s license number

State

Do you have a valid U.S. driver’s license?

YESNO

What is your anticipated salary with trinity life care inc?

Per

HourYear

Have you previously applied with trinity life care inc?

YESNO

Have you ever been employed by trinity life care inc?

YESNO

Do you have any relatives employed trinity life care inc?

YESNO

Have you ever been dismissed, terminated, or asked to resign by a previous employer?

YESNO

EDUCATION BACKGROUND

HIGH SCHOOL

Did You Graduate?

YESNO

Degree/Major

School Name

Location (City/State)

TRADE/BUSINESS

Did You Graduate?

YESNO

Degree/Major

School Name

Location (City/State)

COLLEGE/UNIVERSITY

Did You Graduate?

YESNO

Degree/Major

School Name

Location (City/State)

GRADUATE/OTHER

Did You Graduate?

YESNO

Degree/Major

School Name

Location (City/State)

CURRENT EMPLOYMENT

Present Employer

Position Title

Street Address

Date

City

State

Zip Code

Starting Salary

Phone Number

Supervisor

Current Salary

Description of responsibilities

PREVIOUS EMPLOYMENT HISTORY

**Start with most recent employer first. Please list up to 3 previous employers, including any international work.

Employer

Position Title

Street Address

City

State

Zip Code

Start Date

End Date

Starting Salary

Last Salary

Phone Number (or email if outside of U.S)

Supervisor

Description of responsibilities

Reason for leaving

Employer

Position Title

Street Address

City

State

Zip Code

Start Date

End Date

Starting Salary

Last Salary

Phone Number (or email if outside of U.S)

Supervisor

Description of responsibilities

Reason for leaving

Employer

Position Title

Street Address

City

State

Zip Code

Start Date

End Date

Starting Salary

Last Salary

Phone Number (or email if outside of U.S)

Supervisor

Description of responsibilities

Reason for leaving

Please explain any signaicant gaps in employment (i.e. for school, caring for a child, etc.)

EMPLOYMENT REFERENCES

Please list three current or past supervisors, managers, co-workers, etc.

Name (First and Last)

Relationship to applicant

Name of Business/Employer

Contact Number(s)

Name (First and Last)

Relationship to applicant

Name of Business/Employer

Contact Number(s)

Name (First and Last)

Relationship to applicant

Name of Business/Employer

Contact Number(s)

Have you ever worked with developmental disabilities?

YESNO

What accommodations, if any, are necessary for you to fulfill the job requirements of the position for which you are applying?

Additional comments by applicant, if desired:

AGREEMENT

Read carefully before signing this application.

I am aware that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date
I understand that if hired, my employment can be terminated with or without notice at any time, for any reason.
I understand that no management official is authorized to make any assurance or promise of continued employment and that any such pledge or agreement related to continued employment must be in writing and signed by the Executive Director.
It is the policy of CALMRA, Inc. that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the work place.
I understand that if hired, I must be drug and alcohol free when I report to work.
I also understand that CALMRA may, at any time, institute drug testing, and that all employees (full-time and part-time) may be required to report for drug testing according to an established schedule.
I authorize employers (past and present), schools and other individuals or organizations named in this application and/or accompanying resume to provide any relevant information that may be required to arrive at an employment decision.
I give permission for information regarding my work performance to be released to CALMRA, Inc., and I understand that this information will be treated as confidential and will not be divulged to me.
I authorize CALMRA, Inc. to seek any disclosable information regarding me from the Central Registry of Abuse, which is maintained by the Office of Licensing Certification Programs.
I also authorize the Office of Licensing Certification Programs to release the above mentioned information to CALMRA, Inc.
A photocopy or fax of the release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature.