Employment Application Basic InformationAll fields in this section are required Full Name *First name and last nameEmail *ex. JoeSmith@gmail.comPhone *Position Desired *CNA, HHA, RN, LPN, Housekeeper, Administrator, etc.Date Available *Let us know when you can begin.Full Address *Street, City, State & Zip Driver's LicenseDo you have a valid Driver's License? *YesNoClass Class D - PassengerClass AClass BClass CUnsure / Unknown / OtherDriver's license number: Ex. S91328862 Employment QuestionnaireInstructions Each question is required to be answered. Answer yes or no to each question. Please fill out the optional detail field after answering each question.Have you ever served in the military? *YesNoDo you speak any other languages? *YesNoIf you do speak other languages, please specify: Language and fluency level. Ex: "I can read, write and speak Spanish fluently. I can speak French but cannot read or write it."Can you perform the essential functions and responsibilities of the position for which you are applying? *YesNoIf not, please explain: Do you require any special accommodation to perform required duties? *YesNoIf yes, please explain: Have you ever worked for EpicWellness? *YesNoIf yes, give date(s) of employment and position(s) held: Do any of your relatives work for EpicWellness? *YesNoIf Yes, state their name(s): Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation? *If yes, written documentation will be required about criminal offenses from the clerk of court in the county in which the conviction was made, and about any driving offenses other than minor traffic violations from the mo‐ tor vehicles office.YesNo References (1 of 3)Instructions You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field.Full Name *Full Address Street, City, State & ZipPhone Number: *Relationship *Ex. Former boss, Co-worker, Teacher, Instructor, etc. References (2 of 3)Instructions You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field.Full Name *Phone *Relationship *Ex. Former boss, Co-worker, Teacher, Instructor, etc.Full Address Street, City, State & Zip References (3 of 3)Instructions You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field.Full Name *Phone *Relationship *Ex. Former boss, Co-worker, Teacher, Instructor, etc.Full Address Street, City, State & Zip Education and SkillsLevel of education completed *GEDHigh SchoolCollege: 0-3 YearsCollege: Associates' DegreeCollege: Bachelors' DegreeCollege: Masters' DegreeIf you have a degree, please specify major How many words per minute can you type? Only enter if knownProficient software applications Experience (1 of 3)Instructions Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom. If this is your first job, enter in your school graduation details below.Start Date *End Date *Name of Employer *May we contact your former employer? *YesNoFull Address *Street, City, State & ZipSupervisor's Name *Phone Number *Title and Duties Performed *Reason for Leaving * Experience (2 of 3)Instructions Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom.Start Date End Date Name of Employer May we contact your former employer? YesNoFull Address Street, City, State & ZipSupervisor's Name Phone Number Title and Duties Performed Reason for Leaving Experience (3 of 3)Instructions Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom.Start Date End Date Name of Employer May we contact your former employer? YesNoFull Address: Street, City, State & ZipSupervisor's Name Phone Number Title and Duties Performed Reason for Leaving Experience: Additional JobsTell us about any additional jobs in the past 5 years here Sign and SubmitBy submitting this form you agree To carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment. I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about my citizenship and employment history. I also certify that I understand all questions and statements on this application.Checkbox *AcceptanceI HAVE READ AND UNDERSTAND THE LEGAL INFORMATION ABOVEUnderstandings & Signature You understand that Epic Wellness will rely upon your electronic signature to the same extent as if you had signed this document in ink. If you do not understand or accept or agree to the terms and conditions set forth above, then do not submit. By entering the your name and date of birth below you signify that you understand and agree to the terms above.Full Name *Today's Date * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
