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Job Application Form

Job Application Form

Family Wellness, LLC is an equal opportunity employer. All applicants and employees will be treated fairly and in conformity with all existing laws.

Family Wellness LLC will hire only U.S. citizens or aliens authorized to work in the U.S.

Write or print specific and accurate answers to all questions in detail (except as noted above.) all information will be treated confidentially.

*First Name:

*Last Name:

*Middle Initial:

*Address:

*City:

*State:

*Zip Code:

Home Phone Number:

Cell Phone Number:

*E-mail Address:

*What position(s) are you applying for:

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Shift desired - check all that apply:

Full time Part time Temporary Day Evening Weekend

Date available to begin employment:

Minimum salary desired:

How did you learn about this position:

Newspaper School Employee Recruiting Fair Radio/TV Internet Other

*If other, please specify:

*Are you eighteen years of age or older? (if under 18, hire is subject to verification of the minimum legal age.)

Yes
No

*Are you a citizen of the United States or otherwise lawfully authorized to work in the U.S.?

Yes
No

*Have you attended school or been employed under another name?

Yes
No

*If yes, under what name(s)?

*Have you ever been convicted of a crime? (Excluding minor traffic violations):

Yes
No

*If yes, please explain: (Conviction will not necessarily disqualify an applicant for employment.)

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Education and Qualifications

High School Name:

High School City/State:

High School Degree/Diploma:

*Date Received:

College Name:

College City/State:

College Degree/Diploma:

College Diploma Date Received:

College Major Field:

Technical School Name:

Technical School City/State:

Technical School Degree/Diploma:

Technical School Diploma Date Received:

Technical School Major Field:

Professional/Technical Licenses and/or Certification

Professional/Technical License or Certification #1:

Type:

State Issued:

Date Issued:

Number:

Expiration Date:

Professional/Technical License or Certification #2:

Type:

State Issued:

Date Issued:

Number:

Expiration Date:

Professional/Technical License or Certification #3:

Type:

State Issued:

Date Issued:

Number:

Expiration Date:

Has your license or certification ever been suspended or revoked?

Yes
No

*If yes, when:

Special Skills and Qualifications

Summarize special job related skills and qualifications acquired from employment or other experience.

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References

Reference #1

Name:

Company:

City and State:

Present Title:

Telephone Number

Reference #2

Name:

Company:

City and State:

Present Title:

Telephone Number:

Reference #3

Name:

Company:

City and State:

Present Title:

Telephone Number:

Work Experience
(Start with your present or last job - include military service and periods of unemployement)

Employer #1

Employer:

City and State:

Job Title:

Supervisor:

Telephone Number:

From month/year to month/year:

Work Performed

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Reason for Leaving:

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Employer #2

Employer:

City and State:

Job Title:

Supervisor:

Telephone Number:

From month/year to month/year:

Work Performed:

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Reason for Leaving:

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Employer #3

Employer:

City and State:

Job Title:

Supervisor:

Telephone Number:

From month/year to month/year:

Work Performed:

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Reason for Leaving:

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Employer #4

Employer:

City and State:

Job Title:

Supervisor:

Telephone Number:

From month/year to month/year:

Work Performed:

characters remaining

Reason for Leaving:

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Attach resume (Only Microsoft Word (.doc/.docx), TXT and PDF files are allowed. (Max size: 2MB))

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if employed, false information contained in this application may result in immediate discharge at any time during my employment.

I authorize any person or entity listed in this application to provide information which Family Wellness, LLC may request in its evaluation of my qualifications for employment. I further agree that Family Wellness, LLC may furnish like information to those with whom I may seek employment in the future. I release all parties from all liability for any damage that may result from such furnishing of information to or by Family Wellness, LLC.

I understand that if hired the terms, conditions, compensation, benefits, hours, schedules and duration of employment may be determined, changed or modified from time to time by Family Wellness, LLC. I understand if hired that my employment is at will and can be terminated, with or without cause, and with or without notice, at any time at the option of Family Wellness, LLC or myself.

I understand that any offer of employment that may be extended will be conditional and include, but is not limited to, successful completion of a criminal background check and drug test.

*I Agree:

Please only click the "Submit" button once. Clicking it more than once may result in your application not being properly submitted. Thank you.