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Application for Employment Form
Application for Employment
Today's Date:
Position Applied for:
Personal Information
Name
First
Middle
Last
Are you 21 years or older?
Yes
No
Address & Contact Information
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email Address
Employment & Background Information
How did you learn about NSS?
Referred by NSS employee (name/position/realationship)
School/College
Newspaper
Internet Job Board
Friend/Relative (not employee)
Maryland Job Service
NSS Website
Other
If you answered any option except for NSS Website, please let us know the specific referrer
Have you ever been employed with NSS?
Yes
No
Start Date:
End Date
Position(s)
Why did you leave?
Do you have relatives currently employed by NSS?
Yes
No
Relative's Name
Realationship
Relative's Position
Have you ever been convicted of any crime other than traffic violations?
Yes
No
If yes, please provide information. NSS performs criminal background checks on all employees. Failure to provide complete and accurate information constitutes and could preclude you from employment.
Please enter any crimes you were convicted of here (Charges, Conviction Date, Felony or Misdemeanor, Disposition)
If you have more than one item to enter, please add each on a new line.
If applying for a direct care position, do you have any condition that would preclude you from performing physical restraints if neccesary?
Yes
No
N/A
If a job offer is made, how soon will you be available to work?
Do you have any objections to working overtime?
Yes
No
Can you work overtime without prior notice?
Yes
No
Education
Please list your educational background. Include GED, High School, College and/or Technical & Trade Schools. If a job offer is extended, you will be required to provide educational documentation at time of employment. Please place each new item on a new line.
School Name/Address
# of Years
Grad? Y/N
Yes
No
Degree / Major
Additional Related Training
Include any other training relevant to the position for which you have applied (i.e. CPR, First Aid, DDA, & YIT Training. Med Administration, Computer Skills, and workshops attended. Please include date training was completed and expiration dates if applicable. Please place each new item on a new line.
Training
Date (Month/Year)
Expiration Date
Where Received
Personal References
**Please do not list relatives
Name
Realationship
Occupation
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Please enter phone number for day and night if applicable.
Years Known
Name
Realationship
Occupation
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Please enter phone number for day and night if applicable.
Years Known
Name
Realationship
Occupation
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Please enter phone number for day and night if applicable.
Years Known
Employment History
Please provide a complete and accurate job history for at least the last 6 years, beginning with the most recent. NSS performs employment reference checks on all employees. Failure ti provide complete and accurate information could preclude you from employment with NSS.
Current (or most recent) Employer
Job Title
Supervisor Phone
Employed
Duties
Salary
FT or PT?
Full-Time
Part-Time
If Current, may we contact?
Yes
No
Previous Employer:
Job Title
Supervisor Phone
Employed
Duties
Salary
FT or PT?
Full-Time
Part-Time
Previous Employer:
Job Title
Supervisor Phone
Employed
Duties
Salary
FT or PT?
Full-Time
Part-Time
Statement Regarding Hours of Availability
Name
*
Position Applying For
NSS Understands that employees have interests and obligations other that their work. We encourage our employees to pursue family involvement, religious activities and continued education. We realize that it is necessary to work around other obligations such as childcare and other employment.
Therefore, in an effort to make the scheduling process most effective and satisfying for both the employee and the company we are requiring each applicant to submit their exact hours of availability, keeping other interests and obligations in mind.
Sunday Availability:
From
To
Monday Availability:
From
To
Tuesday Availability:
From
To
Wednesday Availabilit:y
From
To
Thursday Availability:
From
To
Friday Availability:
From
To
Saturday Availability:
From
To
Submit