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________________