* = Required Information
Yes No

If less than 1 year, previous address:

Yes No
Yes No
Yes No

Sun Mon Tue Wed Thur Fri Sat
Full-time Part-time PRN
Yes No

Education:

Employment or activity history for the past 5 years must be given: (Former employers may be contacted unless you give us reason we may not contact them)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

APPLICANT AUTHORIZATION:

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein for the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have to help me obtain employment with Abundant Care, LLC.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such a change is specifically acknowledged in writing by the Executive Director.

IT IS OUR POLICY TO COMPLY WITH ALL APPLICABLE STATE AND FEDERAL LAWS PROHIBITING DISCRIMINATION IN EMPLOYMENT BASED ON RACE, AGE, COLOR, SEX, RELIGION, NATIONAL ORIGIN, OR OTHER PROTECTED CLASSIFICATIONS.

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