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Job Application

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

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Date

YYYY dot MM dot DD

APPLICATION FOR EMPLOYMENT

INSTRUCTIONS: Please complete all sections of this form. Applications are considered for a 90-day period only. Dates requested within the application are only used to verify the accuracy of the information.

Position Applied For:*

Position (Write In):

Employment Status Desired*

Employment Status Desired (Write In)

How Did You Hear About Our Company?*

Facebook

Indeed

KY Healthcare Training

Linked In

Word of Mouth (Referral - Write In)

Not Listed (Write In)

How did you hear about us (Write In)

List When You Are Able To Work?*

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Ex. Monday: 8A-4P, Tuesday: 10A-2P, Wednesday: None

Do You Have Your Own Personal Vehicle?*

Yes

No

Ridesharing, scheduled pick up/drop offs, and rental cars are not considered reliable means of transportation.

Name*

First Last

Current Address

Street Address Bldg. Apt. Suite# City State ZIP Code

Phone*

Is this a smart phone with data capability?

Email*

Social Security Number

Do you have a VALID Drivers License and Active Car Insurance*

Yes

No

Other

Drivers Identification Number

Date of Birth

Are you at least 18 years old?

Current TB Skin Test (no longer than 12 months ago):

TB Skin Test Date

MM slash DD slash YYYY

Emergency Contact Name

First Last

Phone

Relationship

Education

High School / GED

Year Graduated

City

State

Did you attend a Technical School?

Yes

No

Technical School

City

State

Degree Obtained

Area of Study

Did you graduate?

Year Graduated

Did you attend a College or University?

Yes

No

College/University

City

State

Degree Obtained

Area of Study

Did you graduate?

Year Graduated

WORK EXPERIENCE

List work experience for the past ten years chronologically from the most recent to oldest. Do not leave gaps.

1: Current/Most Recent Work/Employer*

Start Date

End Date (Leave blank if current)

City

State

Supervisor

Phone

Reason for leaving:

Is this work experience directly related to the job for which you are applying?

How?

Starting Pay

Ending Pay

2: Work/Employer

Start Date

End Date

City

State

Supervisor

Phone

Reason for leaving:

Is this work experience directly related to the job for which you are applying?

How?

Starting Pay

Ending Pay

3: Work/Employer

Start Date

End Date

City

State

Supervisor

Phone

Reason for leaving:

Is this work experience directly related to the job for which you are applying?

How?

Starting Pay

Ending Pay

List more work experience?

Yes

No

Please choose "Yes" if you would like to provide more work experience.

More Experience:

Please include anymore experience you would like to tell us about. Include a description, contact names & numbers, and any more details that you feel are relevant.

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Apply Now at Independence Assistance
Availability Request
Availability Submit
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