APPLICATION FOR EMPLOYMENT
PERSONAL INFORMATION
NAME_____________________________________________________________ Date_ ______________________________________
Last First Middle
SOCIAL SECURITY NO._ - _____________________
PRESENT
ADDRESS_ _____________________________________________________________________________________________________
Street City State Zip HOME PHONE (_ ___________ )_ ______________________________ REFERRED BY_ ______________________________________
EMPLOYMENT DESIRED
POSITION APPlIED FOR: Date you can start___________________________ Salary Desired_ __________________________
(Check one)
REHAB NURSE_____________ RN#_ ___________________________ Expiration Date:________________________________________
REHAB COUNSELOR_ ______CRC#_ __________________________ Expiration Date:_ ______________________________________
MARKETING_______________ CLERICAL_______________________OTHER (Specify)______________________________________
Can you, after employment, submit verification of
your legal right to work in the United States?
Yes
No
Have you ever applied at PRO Inc. before?
When?
Where?
Yes
Job
Can you travel if the job requires it?
Are you willing and able to work overtime?
Yes
No
No
Have you ever worked for PRO Inc. before?
If yes, give date(s) and job
Yes
No
Yes
No
If the job requires it, do you have a car?
Yes
No
Do you have a valid driver’s license?
Yes
No
Driver’s License No./State_________________________________
Can you perform the essential functions of the job
with or without reasonable accommodations?
Yes
No
If your work or school records are listed under other names, please
specify:
Have you been convicted of a felony? Yes No If yes, explain_______________________________________________
Have you ever been discharged or forced to resign? Yes No If yes, explain_______________________________________________ If relevant to the job applying for, what foreign languages do you speak, read and/or write? ________________________________________
SCHOOL NAME AND LOCATION
EDUCATION
YEAR GRADUATED
NO. YEARS COMPLETED
High School
College
College
Graduate
Graduate
Trade/Business School
MAJOR/DEGREE
EMPLOYMENT DATA (Must Provide All Information)
1. Employer
Date (From/To)
Reason For Leaving
Address
Position
Work Performed
City State Zip
2. Employer
Salary Hr. Mo.
$ Wk. Yr.
Date (From/To)
Company Phone
( )
Reason For Leaving
Address
Position
Work Performed
City State Zip
3. Employer
Salary Hr. Mo.
$ Wk. Yr.
Date (From/To)
Company Phone
( )
Reason For Leaving
Address
Position
Work Performed
City State Zip
4. Employer
Salary Hr. Mo.
$ Wk. Yr.
Date (From/To)
Company Phone
( )
Reason For Leaving
Address
Position
Work Performed
City State Zip
Salary Hr. Mo.
$ Wk. Yr.
Company Phone
( )
Provide other information which you feel is relevant to your application for this position.
Supervisor
Supervisor
Supervisor
Supervisor
______________________________________________________________________________________________________________________________
PROFESSIONAL REFERENCES
1.______________________________________________________________________________(_____________ )_________________________________________________
Name Address Phone Relationship
2.______________________________________________________________________________(_____________ )_________________________________________________
Name Address Phone Relationship
3.______________________________________________________________________________(_____________ )_________________________________________________
Name Address Phone Relationship
As an equal Opportunity Employer it is the policy of PRO Inc to recruit, hire and promote into all job classifications without regard to race, color,
religion, sex, age, national origin or disability.
I certify that answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. If my position involves driving a vehicle, I
will provide a valid driver’s license and insurance certificate. In the event of employment, I understand that false or misleading information given
in my application or interview(s) may result in discharge.
I hereby grant permission to any person, firm or corporation to release to the Company or its representatives any and all information regarding my
past work or employment and my background. I waive any and all claims I might have with respect to the providing of such information.
The protection of confidential business information and trade secrets is vital to the interests and the success of this organization. Such confidential
information includes but is not limited to the following examples: Compensation data; Customer lists; Financial information; Marketing strategies; Pending projects and proposals; Technological data; Technological prototypes. All employees who may be required to sign a non-disclosure
agreement as a condition of employment. Any employee who discloses trade secrets or confidential business information will be subject to disciplinary action (inlcuding possible discharge) and legal action, even if he or she does not actually benefit from the disclosed information.
I further understand and agree that if I am offered employment by the Company, it will be on an at-will basis and will not be for any definite period
of time. This means that either I or the Company may terminate the employment relationship at any time for any reason, with or without cause,
and additionally means that, if offered employment, the Company has no obligation to continue my position, pay or benefits. I further understand
and agree that only the Company President can enter into an agreement on any other terms and he or she can only do so in writing signed by him
or her and the employee in question. I have been given the opportunity to ask questions regarding Company rules and my potential status as an
employee-at-will. No representative of PRO Inc. has made any promises or other statements to me which imply that I will be employed under
any other terms than stated above.
I have read the above prior to signing this Application.
____________________________________________________ _________________________________________
Signature of Applicant Date Rev. 8/07