Job Application Form

Applicant information
Last Name:*
First:*
MI:*
Date:*
MM slash DD slash YYYY
Street Address:*
Apartment/Unit # :*
City:*
State :*
ZIP :*
Phone*
E-mail Address :*
Driver’s License:*
Social Security No. :*
Desired Salary :*
Position Applied for :
Date Available to start :
MM slash DD slash YYYY
Are you a citizen of the United States? :
If no, are you authorized to work in the U.S.? :
Have you ever worked for this company? :
If so, when? :
Have you ever been convicted of a felony? :
If yes, explain :
EDUCATION
High School:*
From :*
MM slash DD slash YYYY
To :*
MM slash DD slash YYYY
Address:*
Did you graduate? :
Diploma (Please provide a copy ) :*
Accepted file types: pdf, doc, docx, jpg, png, jpeg, Max. file size: 50 MB.
Supported file extensions: .pdf .doc .docx .jpg .png .jpeg Maximum File Size 50MB
College:*
From :*
MM slash DD slash YYYY
To :*
MM slash DD slash YYYY
Address:*
Did you graduate? :
Degree (Please provide a copy ) :*
Accepted file types: pdf, doc, docx, jpg, png, jpeg, Max. file size: 50 MB.
Supported file extensions: .pdf .doc .docx .jpg .png .jpeg Maximum File Size 50MB
Other:
From :
MM slash DD slash YYYY
To :
MM slash DD slash YYYY
Address:
Did you graduate? :
Degree (Please provide a copy ) :
Accepted file types: pdf, doc, docx, jpg, png, jpeg, Max. file size: 50 MB.
Supported file extensions: .pdf .doc .docx .jpg .png .jpeg Maximum File Size 50MB
REFERENCES
Please list three professional references:
Full Name :*
Relationship :*
Company :*
Phone*
Address :*
Full Name :*
Relationship :*
Company :*
Phone*
Address :*
Full Name :*
Relationship :*
Company :*
Phone*
Address :*
PREVIOUS EMPLOYMENT
Company :*
Phone*
Address :*
Supervisor :*
Job Title:*
Starting Salary : $*
Ending Salary : $*
Responsibilities :*
From :*
MM slash DD slash YYYY
To :*
MM slash DD slash YYYY
May we contact your previous supervisor? :
Reason for Leaving :*
Company :*
Phone*
Address :*
Supervisor :*
Job Title:*
Starting Salary : $*
Ending Salary : $*
Responsibilities :*
From :*
MM slash DD slash YYYY
To :*
MM slash DD slash YYYY
May we contact your previous supervisor? :
Reason for Leaving :*
Company :*
Phone*
Address :*
Supervisor :*
Job Title:*
Starting Salary : $*
Ending Salary : $*
Responsibilities :*
From :*
MM slash DD slash YYYY
To :*
MM slash DD slash YYYY
May we contact your previous supervisor? :
Reason for Leaving :*
MILITARY SERVICE
Branch :
From :
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Rank at Discharge :
Type of Discharge :
If other than honorable, explain :
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature :*
Date :*
MM slash DD slash YYYY
CASTLE BRANCH
Company Name: Rae's Playze Adult Day

Rae's Playze Adult Day (“the Company”) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by CastleBranch, 1845 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. Asa result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. You may also contact the Company to re- quest the name, address, and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available to you should you suspect or find that the Company has not maintained secured records is available to you upon request.

Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

ACKNOWLEDGEMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and ASUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, schoo! or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by CastleBranch, 1845 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma applicants or employees only:
- Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.
- Please check this box if you would like to receive a copy of an investigative consumer report or c r credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under Cali- fornia law.
Last Name :*
First :*
Middle :*
Suffix :*
Other Names/Maiden/Alias :*
Social Security# :*
Date of Birth :*
MM slash DD slash YYYY
Driving License# :*
State :*
Phone :*
Email :*
Present Address :
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
*This information will be used for background purposes only and will not be used as hiring criteria. [Note: If you do business in Utah, you cannot ask for DOB, driver's license, or SSN until either a confidential offer of employment or at the time the background report will be run.]
Signature :*
Date :*
MM slash DD slash YYYY
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Job Application Form

Applicant information

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE

CASTLE BRANCH

For Employer Use Only: Please Check mark the searches to be conducted.