Employment Application

EMPLOYMENT HISTORY
List all previous employers for whom you have worked during the last five years. Explain any lapses between times when employed.
EMPLOYMENT #1
Name of Company*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Dates of Employment*

Start Date
End Date*

End Date
Salary*
Position Held*
Supervisor's Name*
Reason for Leaving*
EMPLOYMENT #2
Name of Company*
Address*
Street Address Address Line 2 City State ZIP Code
Dates of Employment*

Start Date
End Date*

End Date
Phone*
Salary*
Position Held*
Supervisor's Name*
Reason for Leaving*
EMPLOYMENT #3
Name of Company*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Salary*
Dates of Employment*

Start Date
End Date*

End Date
Position Held*
Supervisor's Name*
Reason for Leaving*
Questions regarding employment history
Comments regarding lapses if applicable:*
Have you ever been discharged from a job or forced to resign?*
- Yes
- No
If yes, explain:*
Have you ever been counseled, verbally or in writing, for violation of a prior employers safety rules?*
- Yes
- No
If yes, explain:*
Have you ever been counseled, verbally or in writing, for violation of any company policy of a prior employer?*
- Yes
- No
If yes, please explain:*

MILITARY SERVICE RECORD
The hiring and re-employment of veterans will be conducted in accordance with applicable state and federal laws and regulations.
Are you a member of a Reserve or National Guard unit?*
- Yes
- No
Were you in the U.S. Armed Forces?*
- Yes
- No
If yes, what branch? List what type of Discharge, Dates of Duty (From and To):*
List duties in the military or special training that prepared you for the position you are seeking.
I hereby state that the information given by me in this application is true in all respects. I agree that, if I am employed and the information is found to be false in any respect, I will be subject to dismissal without notice at any time. I hereby authorize my former employers to release information pertaining to my work record, my work habits, and my work performance. In making application for employment, I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I understand and agree that any employee handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of the Enterprise Health and Rehabilitation Center's current policies. I understand that the Enterprise Health and Rehabilitation Center reserves the right to require its employees to submit to blood tests or urinalysis for alcohol or drug screens, or allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood tests or search, when requested to do so, may result in termination of my employment. I understand and agree that, if I am offered employment by Enterprise Health and Rehabilitation Center, my employment will be for no definite term and that either I, or Enterprise Health and Rehabilitation Center, will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice and that this relationship can only be modified in writing and signed by the Administrator.

Signature counts as your legal signature.
Date:
Authorization and Release for the Procurement of a Consumer and/or Investigative Consumer Report
As part of its employees' selection process, Enterprise Health and Rehab routinely obtains consumer reports and/or credit information on applicants for employment and employees applying for promotions. The information contained in these reports may be used to deny an individual employment with Enterprise Health and Rehab or to deny an employee a promotion to a particular position. I, the undersigned consumer, do hereby authorize Enterprise Health and rehab, by and through an independent contractor, Steve Weekly (the "Agency") to procure a consumer report and/or investigative consumer report on me. These above-mentioned reports may include, but not limited to, employment and education verifications; personal references; personal interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and/or any other public record. I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report prepared on me upon my written request to the Agency that is made within a reasonable time after the date hereof. I also understand that I may request a written summary of my rights under 15 U.S.C 1681 et. seq. I further authorize any person, business entity, or governmental agency who may have information relevant to the above to disclose the same to Enterprise Health and Rehab, by and through the Agency, including, but not limited to, any courthouse, any public agency, any and all law enforcement agencies and any and all credit bureaus, regardless of whether such person, business entity or governmental agency the information itself or received it from other sources. I hereby release Enterprise Health and Rehab, the Agency, and any and all persons, business entities, and governmental agencies, whether public or private, from any and all liability, claims, and/or demands, of whatever kind, to me, my heirs, or others making such claim or demand on behalf, for procuring, selling, providing, brokering and/or assisting with the compilation or preparation of the consumer report and/or investigative consumer report hereby authorized.
Name*
First Last
Add your full name, First, Middle, and Last which will be counted as your legal signature of the above Authorization and Release for the Procurement of a Consumer and/or Investigative Consumer Report.
Date*
MM slash DD slash YYYY
Maiden or Other Names Used*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Former Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Security Number*
Daytime Phone*
Driver's License Number*
State of Issuance*
Date of Birth*
Gender*

Without the above information, we will be unable to properly identify you in the event we find adverse information during the course of our background search. Thank you!
Resume
Resume
Accepted file types: pdf, Max. file size: 24 MB.
Please attach your resume here. Only pdf files will be accepted. Thank you!

PERSONAL INFORMATION

If you have lived at the above address less than 12 months, list previous address:

RECORD OF EDUCATION

EMPLOYMENT HISTORY

EMPLOYMENT #1

EMPLOYMENT #2

EMPLOYMENT #3

Questions regarding employment history

MILITARY SERVICE RECORD

Authorization and Release for the Procurement of a Consumer and/or Investigative Consumer Report

Resume