Date *
First Name *
Middle Name
Last Name *
Date of Birth *
Social Security Number *
Telephone *
Email *
Address *
Previous Address (If at current address less than 1 year.)
Position Applied For
School, Location
Dates
Degree/Diploma
Course of Study
License/Certification Type
License/Certification Number
State of Issuance
Expiration Date
CPR Expiration Date
Last Physical Exam Date
Lab TB/Chest X-Ray Date
Are you legally authorized to work in the USA? YesNo
If you are hired as a team member, you will be required to provide documentation to prove your eligibility to work in the USA.
Have you ever been convicted of a felony or misdemeanor crime? YesNo
This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction. A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone. If yes, state the basis for each conviction and the date of the conviction:
Are you able to perform the tasks according to the job description without accommodation? YesNo
If an accommodation is needed, how would you perform the task and with what accommodation?
How did you hear about CGH? NewspaperTrade PublicationJob Fair/Open HouseEmployment AgencyCGH Team MemberIndeedCraigslist
If you chose CGH team member above, what is the CGH team member's name?
Have you ever applied with this company before? YesNo
If Yes, when?
Have you ever worked for this company before?
YesNo
Reason for Leaving?
Starting with present or most recent employment, list all previous employers.
1. Employer
Dates of Employment
Company Address
Title
Salary (Hourly/Yearly)
Job duties & accomplishments
Supervisor
Telehone
May we Contact? YesNo
If no, why not?
Reason for leaving
Are your employment records listed under another name? YesNo
If yes, what name?
2. Employer
3. Employer
Please list any other work related information you think would be helpful to us in considering you for employment, such as foreign language competency, additional work experience, volunteer work, activities, accomplishments, etc.
Please list three individuals with whom you have worked who were in a position to evaluate your performance.
1. Name
Company
Phone
2. Name
3. Name
Celebration Group Homes is an equal opportunity employer.
