Brandi's Hope Community Services

EMPLOYMENT APPLICATION

Supporting Documentation to accompany application
(available to images upload below):

1. Driver’s License
2. Professional License if applicable
3. High School Diploma or Equivalency
4. College Transcript and Diploma if applicable

Equal Opportunity Employer and Drug Free Workplace

Referred by:

 


Brandi’s Hope Community Services ("Company") is an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation, genetic background or physical or mental disability.

PERSONAL

*Last Name: *First Name: Initial: Part or Full Time:

Other Names Used: Home Phone:
Address
City
State
Zip
Cell Phone:
Mailing Address (if different from above): Other Phone:
Email: Position Applied For: Salary Desired:
Interviewed with the Company or its affiliates before? If yes, list date(s), job title(s) & location(s)

Employed by the Company or its affiliates before? If yes, list date(s), job title(s) & location(s)

Any relatives employed by the Company or its affiliates? If yes, list date(s), job title(s) & location(s)

Are you at least 18 years old?
If under 18, do you have a work permit?

This information will not be used to determine your employment eligibility. It is used only to fulfill specific requests by clients for either male or female caregivers and for DOL requirements.

Are you legally eligible for employment in the United States?

EDUCATION

Highest Grade Completed: (Required - if none available, type N/A)
School Name Address Major Studies Degree, Diploma,
License or Certificate
High School: (Required)
College: (Required)
Vocational:

Other Special Knowledge, Skills or Qualifications:

List Any Professional Designations:
Primary Language Spoken:
Other Language Spoken:

EMPLOYMENT HISTORY

List all employment for the past 10 years, starting with the most recent position. All information must be completed. You may attach a resume, but not in place of completing the required information.

Employer 1 (Required)

Employed from: Employer Name:
Supervisor Name: Starting Salary / Hourly Rate:
Employed Until: Employer Address: Supervisor Phone: Ending Salary / Hourly Rate:
Job Title: Reason for Leaving:
Duties and Responsibilities:
OK to contact this employer?  

Employer 2 (Required)

Employed from: Employer Name:
Supervisor Name: Starting Salary / Hourly Rate:
Employed Until: Employer Address: Supervisor Phone: Ending Salary / Hourly Rate:
Job Title: Reason for Leaving:
Duties and Responsibilities:
OK to contact this employer?  

Employer 3 (Required)

Employed from: Employer Name:
Supervisor Name: Starting Salary / Hourly Rate:
Employed Until: Employer Address: Supervisor Phone: Ending Salary / Hourly Rate:
Job Title: Reason for Leaving:
Duties and Responsibilities:
OK to contact this employer?  

GENERAL

May we contact your current employer for references?
Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?
Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court? (A 'yes’ response does not automatically disqualify your application.)

REFERENCES (REQUIRED)

List three references. One reference must be from a former employer. The other two references must be from 'non-family’ members. Brandi’s Hope requires the addresses and phone numbers for all references.

Reference Name Reference Address Reference Phone

OTHER INFORMATION

Please describe briefly why you would like to work for Brandi’s Hope:

Describe what characteristics you possess that would make you a valuable employee for Brandi’s Hope.


Do you own reliable transportation?
If yes, do you have at least the minimum state required liability insurance on this vehicle?

EEO/OFCCP Demographic Data (Voluntary Self-Identification)

Government regulations require employers to keep basic demographic data on all applicants. Completion of the following questions is voluntary and is not part of the official employment application. Your assistance is appreciated.

Postition Applied For: Name:
Address: Referral Source:  

Please check the appropriate items to the right:














Equal Opportunity Employer

CERTIFICATION & AUTHORIZATION

The above information is true and correct. I understand that, in the event of my employment by the Company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.

I authorize the Company to inquire into my educational, professional, past employment and public criminal background history, and to contact my references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information.

I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing.

The document(s) provided will be used for completion of Form I-9.

I hereby acknowledge that I have read and agree to the above statements. (By typing your name and submitting below, you agree to these terms)

File Attachments (you may attach an image to the buttons below)

Driver's License:


Professional License (if applicable):


High School Diploma or Equivalency:


College Transcript and Diploma if applicable:


CPR Card:


Auto Insurance Card:

Name/Signature:


(Click submit only once. It may take a few moments for larger attachments. If error message is received, use back button to return)