Application for Employment

 
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APPLICANT INFORMATION
EMERGENCY CONTACT INFORMATION
A work or home number is required
EDUCATION
EMPLOYMENT HISTORY - In order from the LATEST to the OLDEST
Position/Applicant Information
REFERENCES - Two Professional One Personal (Relatives are not acceptable references)
INDEPENDENCE, INC. selects the most qualified individuals for the job, based upon job-related qualifications, regardless of race, color, creed, sex, national origin, age handicap, or other protected groups under state, federal, or local Equal Opportunity Laws.
I understand and Agree That:
1. Any material misrepresentations, or deliberate omission of a fact in my application may be justification for refusal of or, if employed, termination from employment.
2. It is my understanding that INDEPENDENCE, INC. will make a thorough investigation of my entire work history and may verify all data given in my application for employment, drug test/screen, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by INDEPENDENCE, INC. and I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.
3. It is my understanding that I am expected to keep the Director of Human Resources informed in writing of any changes in my status within three (3) working days of the change. This includes notification of any change in Motor Vehicle license status (including any citations issued) and criminal records status (including arrests).
Name and Date