Native Angels Employment Application
 PERSONAL
Last Name: First Name:
MI:
Address:
 City:
 State:
 Zip Code:
 Day Phone: (required) (digits only)
 Cell Phone: (digits only)
  Have you been a resident of North Carolina for five(5)years or more? Yes    No
  If not, Please list previous address
 
  What hours are you available?
  Position applied for?
 
 Salary Desired?
  How were you referred to company?
 
  Are your applying for?
Full Time    Part Time    Regular    Temporary
  Relatives or friends employed by company? Yes    No  Department?

  Date available for employment?  Date:
  Have your ever been employed by this company?
  Yes    No
When?  
  Reason for leaving?
 
  Emergency contact?
  Emergency phone number?
  Relationship?
  Are you a U.S. citizen or an alien legally authorized to work in the United States? Yes    No
  Have you ever been convicted of a felony? Yes    No
  If convicted of a crime, please explain?
 
  After reviewing the functions of the job you are applying for, are you able to perform all essential functions of the job?
Yes    No
 
 If not, is there a reasonable accomodation that can be made?
 
 
 EDUCATION
School Name & Address of School Course of Study Years
Completed		 Did You
Graduate		 List Diploma
or Degree
 High
 College
 Other
 Area of specialization or major interest?
 
  Typing: approx wpm?  
  List health care, business or industrial equipment operated?
 
 
 PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
Are you currently: Registered Licensed Certified
Eligible for: Registration Licensure Certification
 If licensed, registered, or cerified
Type State issued Date No.
  Is there currently any action or activity in process against professional license or certification? Yes    No
  If yes please explain:
 
 
 EMPLOYMENT HISTORY (Most Recent Jobs First)  
 Employer Name:
  Dates:  To
 Address:
 Immediate Supervisor:
  Salary?
  Reason for leaving?
  Job title:
  Job duties:
 
 
 Employer Name:
  Dates:   To
 Address:
  Immediate Supervisor:
  Salary?
   Reason for leaving?
  Job title:
  Job duties:
 
 
 Employer Name:
  Dates:   To
 Address:
 Immediate Supervisor:
  Salary?
   Reason for leaving?
  Job title:
  Job duties:
 
 
 Employer Name:
  Dates:  To
 Address:
 Immediate Supervisor:
  Salary?
  Reason for leaving?
  Job title:
  		  Job duties:
 
  State if you do not want us to contact any of the above listed former employers and the reason you do not want each contacted.
 Can we run a detailed employment check, including but not limited to a check with your previous employers?
Yes    No

Please type your full name here to authorize reference check
 
 REFERENCES
 (Employment Contact)
 Name and Relationship:
  Title:
 Company Name & Address:
  Phone:
 
 Name and Relationship:
  Title:
 Company Name & Address:
  Phone:
 
 Name and Relationship:
  Title:
 Company Name & Address:
  Phone:
 

  READ THIS SECTION PRIOR TO SUBMITING THIS APPLICATION


 In consideration of my employment, I agree to conform to the rules and regulations of this company. I understand that employment with Native Angels is "at-will" and may be terminated at any time and for any reason, at the option of  either the company or myself. I understand that no one has authority to enter into any agreement or employment for any specified period or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of the company.

 I hereby affirm that the information provided on the application (an accompanying resume, if any) is true and complete. I understand that any false or miseading representations or omissions may disqualify me form further consideration for employment and may result in descharge even if discovered later.

 Native Angels does not guarantee any specific number of hours or shifts and that I may or may not be assigned. I understand I must call everyday or come in one (1) time each week for work assignment. I understand if client is hospitalized or expired that I must find other work. However, I agree that I will not become employed by any client where Native Angels have previously assigned me for a period of three months following termination of my employment with Native Angels. (Aide and CSW Technician)
 
 I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizanizations named in this application (and accompanying resume, if any) to provide this facility and all affiliates with any relevant information regarding and employment decision, I release Native Angels and any individual or entity providing information to Native Angels from any legal liability regarding the provision or use of such information
 
 To apply for this position, click the "Submit Application" button to indicate that you understand and accept these terms. Your application will then be submitted. If you are the successful candidate, you will be asked to sign a copy of this application.

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