Provide the following information for your past and current employers,
assignments or volunteer activities, starting with the most recent
(use additional sheets if necessary). Explain any gaps in employment
in comments section below.
List professional, trade, business, or civic associations and any offices held.
Exclude memberships which would reveal sex, race, religion, national origin, age, color,
disability or any other similarly protected status.
List special accomplishments, publications, awards, etc. Exclude information, which would reveal sex,
race, religion, national origin, age, color, disability or any other similarly protected status.
List any additional information you would like us to consider.
Please Read and Sign
I understand that if I am employed, any misrepresentation or material
omission made by me on this application will be sufficient cause
for cancellation of this application or immediate discharge from
the employer’s service, whenever it is discovered.
I give the employer the right to contact and obtain information
from all references, employers, educational institutions, criminal
background checks, child abuse checks, and personal references,
and to otherwise verify the accuracy of the information contained
in this application. I hereby release from liability the employer
and its representatives for seeking, gathering and using such
information and all other persons, corporations or organizations
for furnishing such information.
The employer does not lawfully discriminate in employment and
no question on this application is used for the purpose of limiting
or excusing any applicant from consideration for employment on
a basis prohibited by local, state or federal law.
This application is current for only 180 days. At the conclusion
of this time, if I have not heard from the employer and still
wish to be considered for employment, it will be necessary to
fill out a new application.
I understand that if I receive an offer of employment it will
be conditioned on successfully completing drug testing that I must
undergo before starting work. I hereby agree to submit to drug
testing and consent to allow Supportive Concepts and any person
or entity it may designate to perform drug testing on me. I also
agree that the results of the drug testing may be divulged to
If I am hired, I understand that I am free to resign at any time,
with or without cause and without prior notice, and the employer
reserves the same right to terminate my employment at any time,
with or without causes and without prior notice, except as may
be required by law. This application does not constitute an agreement
or contract for employment for any specific period of definite
duration. I understand that no representative of the employer,
other than an authorized officer, has the authority to make any
assurances to the contrary. I further understand that any such
assurances must be in writing and signed by an authorized officer.
I understand it is this company’s policy not to refuse to hire
a qualified individual with a disability because of that person’s
need for a reasonable accommodation as required by the ADA.
I also understand that if I am hired, I will be required to provide
proof of identity and legal work authorization.
I represent a warrant that I have read and fully understand the
foregoing and seek employment under these conditions.
SIGNATURE OF APPLICANT:
DATE: April 21, 2015