Application APPLICATION FOR EMPLOYMENTName Date MM slash DD slash YYYY Address Street Address PhonePosition(s) you are applying forAre you available full time? Are you available part time? (specify)What hours can you work? When would you be available for employmentWere you previously employed here? if yes, please specify dates of employment: State your reason(s) for leavingHave you ever been convicted of a crime? if yes, please describe:*NOTE: COLORADO REGULATIONS REQUIRE THAT A CRIMINAL HISTORY CHECK BE DONE ON ALL EMPLOYEES IN THE RESIDENTIAL CARE SETTING.EDUCATION RECORDSCHOOL Elementary School High School College Other CITY / STATE CITY / STATE CITY / STATE Other CITY / STATE Select Year Completed 5 6 7 8 Select Year Completed 1 2 3 4 Select Year Completed 1 2 3 4 Enter Year Completed What Diplomas, Degrees, Or Certificates Have You Been Awarded?EMPLOYMENT RECORDDATES OF EMPLOYMENTNAME/ADDRESS/PHONE # OF EMPLOYERREASON FOR LEAVING Add RemoveDate Of Birth MM slash DD slash YYYY Social Security Number Marital Status: Single Married Number of Dependents Name, Address, And Phone Number(s) Of Person To Be Notified In Case Of An Emergency:Do you have any physical and/or mental conditions or disabilities which may limit your ability to perform the job description(s) for the position(s) you are applying for? Yes No Yes, list the specific conditions/disabilities and specify how they would limit your ability to perform the job:I understand that it will be necessary for me to complete a health questionnaire and/or to have a physical examination as required by state regulations prior to employment with this facility.I understand that all personnel must have screening for tuberculosis as a condition of employment in this residential care setting as required by state regulations.I understand that the facility must check my “criminal history” and my past employment record during the application process.I also understand that if employed, false statements on this application form may be considered cause for dismissal.Applicant’s signature:Date MM slash DD slash YYYY
