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PERSONAL INFORMATION: First Name: Middle Name: Last Name: Street Address: City: State: Zip Code: Phone Number: Are you eligible to work in the United States? Are you over the age of 18? Have you been convicted of or pleaded no contest to a felony within the last five years? If yes, please explain: Position Applied For: Days/Hours Available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours Available: from to What date are you available to start work? EDUCATION: Name and Address Of School - Degree/Diploma - Graduation Date: Skills and Qualifications: Licenses, Skills, Training, Awards: EMPLOYMENT HISTORY: Present Or Last Position: Employer: Address: Supervisor: Phone: Email: Position Title: From: To: Responsibilities: Salary: Reason for Leaving: =========== Previous Position: Employer: Address: Supervisor: Phone: Email: Position Title: From: To: Responsibilities: Salary: Reason for Leaving: May We Contact Your Present Employer? References: Name/Title Address Phone I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above. Signature: Date: PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION I,______________________, understand that as part of the employment process, Active at Home Helpers needs to complete a background check on me regarding: 1. Criminal record; 2. Sex and Violent Offenders Record; 3. Employment Verification; 4. Education Verification; 5. License Verification; 6. Motor Vehicle Records; 7. Personal/Professional Reference Verification; 8. Medical Suitability 9. Drugs/Alcohol Full Name: Telephone No: Former Name(s) and Date(s) used: Date of Birth: Social Security Number: Current Driver’s License: State: