Homeplace on Green River, Inc.,

Contract for Labor Application

APPLICANT INFORMATION

Last Name____________________________________
 
First Name____________________________________
 
Middle initial___________________________________      Date_________________
 
Street Address_________________________________________________________
Apt/Unit#
 
City_______________________________________
 
State and Zip Code  _________________________
 
Home Phone_______________________________
 
Cell Phone_________________________________
 
Email Address______________________________

Date Available______________________________
 
Have you been convicted of a crime other than a traffic offense?  (Please note:  Convictions are not grounds for automatic rejection)
 
Are you willing to take a drug screen for illegal use according to our policy?  Yes   No


EDUCATION

High School__________________________________

Address: ____________________________________       From________  To_______

Did you graduate?    Yes____   No____
 

College
 
Address______________________________________________________________
 
From______________________________
 
To________________________________
 
Did you graduate?   Yes____  No____  Degree and Major________________________
 
Other_______________________________
 
Address_______________________________________________________________
 
From___________  To_________________
 
Did you graduate?         Yes_____  No_____   Did you receive a degree?____________
 
 
PREVIOUS EMPLOYMENT

Most Recent Employer__________________________
 
Phone___________________
 
Address______________________________________
 
Supervisor____________________________________
 
Job Title______________________________________
 
Starting Salary____________  Ending Salary_________

Responsibilities_________________________________
 
From_______  To__________ Reason for leaving__________________________
 
May we contact your previous supervisor for a reference?   Yes______ No______

Other Employers____________________________________________________

Phone______________   Address______________________________________
 
Job Title____________________Supervisor______________________________
 
Starting Salary____________  Ending Salary:__________


Will you release your background information inclusive of criminal records?  Yes_____  No______


DRUG SCREEN AUTHORIZATION AND CONSENT:  I hereby authorize and give full permission to have
Homeplace on Green River, Inc., and/or their medical clinic of their choosing to send a specimen of my urine and/or blood and/or hair follicles to a laboratory for screening test using S.A.M.H.S.A. standards for the presence of illegal drugs.

I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for any alleged harm to me or interfering with my obtaining a job or continuing employment due to not submitting to the tests or as a result of the test.  This includes, but is not limited to, possible clerical or laboratory error.

This policy and authorization has been explained to me in language I understand and I have been told that if I have any questions about the test they will be answered.  I understand this is a legal binding document which is binding because Homeplace on Green River, Inc., is sending me for the examination and paying for it at their expense.

I UNDERSTAND HOMEPLACE ON GREEN RIVER, INC., WILL REQUIRE A DRUG SCREEN

TEST WHENEVER AN ON-THE-JOB ACCIDENT OF INJURY IS REPORTED IN ACCORDANCE

WITH COMPANY POLICY.  MY REFUSAL TO SUBMIT TO DRUG TESTING WILL BE GROUNDS

FOR TERMINATION.        Your Initials________________

REFERENCES

Please list three professional references:

1. Full Name____________________________________  Relationship__________________________
 
Employer/Other____________________________________________
 
Phone_______________   Address_______________________________________________________
 
2. Full Name____________________________________  Relationship__________________________
 
 Employer/Other____________________________________________
 
Phone_______________   Address_______________________________________________________
 

3. Full Name____________________________________  Relationship__________________________
 
Employer/Other____________________________________________
 
Phone_______________   Address_______________________________________________________
 
 
PLEASE READ:  I authorize you to check my references regarding past employer

Signature________________________________________________________  Date_______________
 
 

MILITARY SERVICE

Branch of service__________________________  From_________________  To___________________
 
Rank/ Rate at Discharge____________________  Type of Discharge____________________________
 
If other than honorable, please explain_____________________________________________________
____________________________________________________________________________________
 
 
DISCLAIMER AND SIGNATURE

I hereby declare that all statements contained in this application are true and correct and understand that false or inaccurate

information in the application will be the basis for termination.  I hereby authorize Homeplace on Green River

Inc., to investigate my background inclusive of criminal records and verify this information.  I understand that if employed, my employment is at will and not for any fixed period of time and may be terminated by  Homeplace on Green River, Inc., or me at any time.  I also authorize The Homeplace on Green River, Inc., to release information contained herein and its findings and work history of my employment to other employers or persons upon request.  I also agree to submit to a drug screen upon request or as specified by Homeplace policy.

Applicant's printed name and signature _____________________________________________________
Date________________