All information provided is confidential and your current employer will not be contacted without your consent. Please print clearly and answer all questions

School Attended, Name of school and address & Diploma/Degree/ Certification
High School
Graduate School
Business School
Aide Training
Professional/Para-professional Licenses and Certifications
WORK HISTORY (Minimum of two (2) years)
1. Company Name
2. Company Name
All information I have provided in this application is true. If employed, I understand that false information on this completed application, is cause for termination. Upon employment, I will comply with all the agency’s rules and regulations regarding my employment. The agency will request information regarding my background which will include work and personal references and criminal background check. I hereby release them and the Agency and its agents from all liability which my follow from the release of such information. The Agency does not discriminate based on sex, age, physical handicap, race, sexual orientation, creed/religion, or national origin. This agency is an equal opportunity employer.

I understand that potential employment will be on an at-will basis, for no definite term. As such, I understand that I will enjoy the right to terminate my employment at any time, and that the agency will similarly possess the right to terminate my employment at any time.