Career Application

Personal Data

Name(Required)

First Middle Last

Social Security Number(Required)

Date of Birth(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Education

Diploma / Degree

School

Location

Graduated?

Special Licenses, Certifications or Registration

List All Relevant Licenses, Certifications or Registrations

License/Certification

Lic./Cert. #

State

Expiration Date

Other Work Related Information

Please list any other work related information that you think would be helpful in your consideration for employment, such as foreign language competency, additional work experience, volunteer work, activities, and accomplishments.

References

Name

Company

Title

Phone #

Please list three individuals with whom you have worked who are in a position to evaluate your performance.

Work Experience

Please complete all appropriate items, even if you have already provided us with a resume.

Company Name(Present or most recent employer)

Employment Start Date

Employment End Date

Currently Employed Here

Yes

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Current Supervisor

First Last

If not, Why?

Describe your most recent job duties and accomplishments:

Explain Reason for Leaving

Company Name(Present or most recent employer)

Employment Start Date

Employment End Date

Currently Employed Here

Yes

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Current Supervisor

First Last

If not, Why?

Describe your most recent job duties and accomplishments:

Explain Reason for Leaving

Company Name(Present or most recent employer)

Employment Start Date

Employment End Date

Currently Employed Here

Yes

Name of Current Supervisor

First Last

If not, Why?

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Describe your most recent job duties and accomplishments:

Explain Reason for Leaving

Criminal Background

Are you legally authorized to work in the USA?

Yes

If you become and employee of Heart of Carrie LLC., you are required to provide documentation proving you are eligible to work in the USA

Have you ever been convicted of a felony or misdemeanor crime?

Yes

(This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.) A criminal conviction does not necessarily bar you from employment. We will consider the nature of the crime, time that has expired since occurrence, and any rehabilitation you have undergone. If Yes: State the basis for each conviction and the date of the conviction.

List Convictions

Basis for Conviction

Date of Conviction

General Background

Are you able to perform the tasks according to the job description without accommodation?

Yes

Describe the accommodation needed to perform the task.

How did you hear about Heart of Carrie LLC.?

Describe the accommodation needed to perform the task.

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize Heart of Carrie LLC. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. if an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by the CEO, the employment relationship will be "at-will". In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the relationship at any time and without cause. With appropriate notice, I will have the full discretion to end the employment relationship when I choose and for reasons of my choice. Similarly my employer will have the right. Moreover, no agent representative, or employee of Heart of Carrie LLC., except in a specific written contract of employment signed on behalf of the organization by it's CEO has the power to alter or vary the nature of the voluntary relationship.

Date of Signing(Required)

Applicant Reference Check (1)

To Whom It May Concern:

The applicant listed below has submitted an application for employment at Heart Of Carrie LLC. Please verify employment and rate of the performance of this candidate. This information will not be given to the employee.

To be filled out by the applicant.

Name

First Last

Date of Application

Previous Employer

Contact Person

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicants Signature

Date

To be completed by previous employer

Employment Start Date

Employment End Date

Would you rehire this individual

Yes

Responsibilities

Reason for leaving

Rate of pay (Weekly/Biweekly/Salary)

Additional Comments (Training Skills)

Reference Check Performed By:

Date