Application_For_Employment

ELDERLY OPPORTUNITY AGENCY, INC.
FORM #	2-1	EOA Application for Employment	REVISED:	05/05

PLEASE PRINT CLEARLY AND USE AN INK PEN

PERSONAL INFORMATION:

Full Name:________________________________________________

Mailing Address:________________________________________________

________________________________________________

Telephone:__________________ Social Security #:_____/____/____

*Are you 18 years of age or in possession of a work permit? Yes___ No___

*Are you either/or U.S. citizen or an alien resident who is authorized to work in the

United States? Yes___No___

**If you answer “YES,” you must complete the I-9 form required by the U.S. Immigration and Naturalization Service no later than three (3) business days after your date of hire.**

EMPLOYMENT DESIRED:

Position for which you are applying:________________________________

After you have completed the remainder of the application, please obtain a job description for the position which you have listed above. After reviewing the job description, please answer the following question.

Can you perform the essential functions with/ without accommodations? Yes___No___

Full-Time ____ Part-Time____ Temporary____ As Needed On Call Help____

Date you are available to start employment:________________________________

Are you available to work overtime, if required? Yes___ No___

BACKGROUND:

*Have you ever applied for employment with this company? Yes___No___

If yes, when?________________ For which position?_______________________

Were you ever employed by this company? Yes___No___

If yes, when?________________ In what position?_______________________

Have you ever been convicted a crime? Yes___No___

(A conviction will not necessarily be a bar to employment. Please describe the nature of the conviction, the date of the conviction and your rehabilitation since your conviction.)

List below your work experience (starting with your present or most recent employer) for the last-ten years or your last six employers, whichever will provide us with the most information about you. Use the reverse side of the application if you need additional space. Please account for all periods of unemployment in this section.

Please list any other skills you may have that might assist you in your employment here at Elderly Opportunity Agency, Inc. or that may be of interest.

______________________________________________________________________________________________

NAME & OCCUPATION ADDRESS PHONE NUMBER

________________________________________________________________________________________

__________________________________________________________________________________

Elderly Opportunity Agency, Inc. is an equal opportunity employer and will not discriminate on the basis of race, creed, religion, color, national origin, ancestry, age, gender, sexual orientation, martial status, atypical heredity, cellular or blood trait, disability (including AIDS and HIV infection) and liability for service in the United States Armed forces or any other legally protected status. Elderly Opportunity Agency, Inc. will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation would impose an undo hardship on the operation of its business.

Please list any other job related experience, skills or activities, including United States Military service experience or volunteer activities, not described above, which you would like us to consider in evaluating your qualifications for the position sought. (You are not required to list any information, which may tend to reveal a protected characteristic as set forth in the EEO statement above.)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I understand that any misstatement, omission or misleading information given in my application or interview or in connection with other Company records may result in the rejection of my application, the withdrawal of any offer of employment or my dismissal from employment.

I authorize an investigation of all statements contained in this application for employment. I agree to allow drug testing or a request of criminal background investigation if required as part of any offer of employment. I release from all liability and responsibility all persons and entities, requesting or supplying information about any information provided on this application, including my present employer.

I understand that if employed by Elderly Opportunity Agency, Inc., I will be an at-will employee, which means that I can voluntarily end my employment or be terminated at any time for any reason or for no reason at all. No statement whether written or oral, by any Company representative other than a written statement signed by the Owners may vary the foregoing.

DATE EMPLOYED	NAME& ADDRESS OF EMPLOYER	NAME OF SUPERVISOR	STARTING POSITION & SALARY	ENDING POSITION & SALARY	REASON FOR LEAVING

Education	School Name & Address	Course of Study / General-Special	Highest Grade Completed
HIGH SCHOOL
COLLEGE
GRADUATE
OTHER

PLEASE PRINT CLEARLY AND USE AN INK PEN

*Are you either/or U.S. citizen or an alien resident who is authorized to work in the

Education

School Name & Address

Course of Study / General-Special

NAME & OCCUPATION ADDRESS PHONE NUMBER