G.S. Burton Development, LLP - "Serving you with care"
Employment Application
Name (First & Last)
Address
City/State, Zip Code
Telephone Number
Alternate Number
Position Applying For?
Are you currently employed?
Yes
No
If yes, may we contact your present employer?
Yes
No
On what date will you be available to begin employment?
What days are you available to work?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What hours are you available to work?
Morning
Afternoon
Evening
Split Shift
Overnight
Have you ever been convicted of a crime or are there any charges pending against you?
Yes
No
Have you ever worked for a direct care agency before?
Yes
No
Are you excluded from working in any direct care or home care agency?
Yes
No
Do you have a current certification in CPR (within the last year)?
Yes
No
Do you have a current certification in First Aid (within the last year)?
Yes
No
Do you have a valid driver's license?
Yes
No
Education
What high school and please indicate if a diploma or GED was earned.
College and course of study.
Other (please specify)
Employment History
Employer
Address
Supervisor's name and phone number?
Position Held?
Job responsibilities?
Employment dates and reason for leaving?
Employer
Address
Supervisor's name and phone number?
Position Held?
Job responsibilities?
Employment dates and reason for leaving?
Please use this space to clarify above answers or general comments.
Equal Opportunity Statement
G.S. Burton Development, LLP fully subscribes to the principles of Equal Employment Opportunity. It is the policy of this agency to provide employment, compensation and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, sexual orientation, veteran status, disability, or any other basis prohibited by federal and state law. In addition I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize verification of any of my information listed above. Please type your name and date to indicate you have read and agree with this statement.