jobapp

Application For Employment

P.O. Box 1348, Wauchula, Fl 33873
800-697-5390

TODAY'S DATE: -- mm/dd/yy REFERRED BY:

First Name

Middle Initial

Last Name

Street Address

City

Address (cont.)

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

E-mail ( optional )
SOCIAL SECURITY NUMBER:

PERSON TO NOTIFY IN CASE OF EMERGENCY:

QUESTIONNAIRE

ARE YOU 18 YEARS OR OLDER?

YES
NO

ARE YOU A CITIZEN OF THE UNITED STATES?

YES
NO

IF NOT, ARE YOU ENTITLED TO WORK IN THE UNITED STATES?

YES
NO

HAVE YOU EVER BEEN CONVICTED OF A FELONY?

YES
NO

IF YES, GIVE DETAILS:

ARE YOU CURRENTLY ADDICTED TO OR DEPENDENT UPON NARCOTICS OR ALCOHOL?

YES
NO

POSITION YOU ARE APPLING FOR:	DATE AVAILABLE:
SALARYDESIRED:
AVAILABLE: REGULAR TEMPORARY PART TIME FULL TIME	DO YOU HAVE A NURSING LICENSE OR CNA CERTIFICATE? YES NO
	HAS THAT LICENSE EVER BEEN SUSPENDED?
IF SO GIVE REASON:
DO YOU HAVE A DRIVERS LICENSE? YES NO	LICENSE NUMBER AND STATE:
HAS YOUR DRIVERS LICENSE EVER BEEN SUSPENDED? YES NO
HAVE YOU EVER WORKED FOR THE FLORIDA INSTITUTE FOR NEUROLOGIC REHABILITATION? YES NO
IF YES PLEASE GIVE DEPARTMENT/ SUPERVISOR / DATE

EDUCATION

HIGH SCHOOL

NUMBER YEARS ATTENDED

DID YOU GRADUATE?

YES
NO

DIPLOMA OR GED

DIPLOMA
GED

COURSES TAKEN

TECHNICAL OR VOCATIONAL TRAINING

TECHNICAL
VOCATIONAL

NUMBER OF YEARS ATTENDED

COURSES TAKEN

NAME OF UNIVERSITY
NUMBER OF YEARS ATTENDED

DEGREE OR DEGREES MAJOR OR MAJORS

LAST PLACE OF EMPLOYMENT

EMPLOYER NAME	EMPLOYER ADDRESS:
START DATE:	END DATE:
EMPLOYER PHONE	EMPLOYER CITY:
EMPLOYER STATE:	EMPLOYER ZIP:
JOB TITLE:	SUPERVISOR:
STARTING SALARY AND OR HOURLY RATES	ENDING HOURLY RATES/SALARY
REASON FOR LEAVING:	SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES
By submission of this form I hereby state to the best of my knowledge that the information given in this application is correct. My permission is given for FINR to make inquiry of any of my former employers and I agree not to hold FINR liable for such inquiries regarding by experience, character, and reason for leaving any and all past employments. I consent to take a physical examination at the request of FINR at no personal expense; and I hereby give all persons conducting the examination permission to reveal any and all details concerning my physical condition to FINR. My failure to give correct and complete information on the application or during a personal interview will be considered grounds for dismissal upon discovery thereof.