VSAandAssociates/HCRG

6571AlturaBlvd.,BuenaPark,CAPhone(562)9457224Fax(562)6982339

EmploymentApplication

APPLICANTINFORMATION
LastName First M.I. Date

Apartment/
StreetAddress
Unit#
City State ZIP

Phone Cell

EmailAddress Fax

Date
SocialSecurityNo. DriversLicense/State
Available
PositionAppliedfor DesiredSalary

Haveyoueverworkedforthis
YES NO Ifso,when?
company?
Doyouhaveanyfriendsorrelatives
Ifso,statename(s)
workingforVSAand YES NO
andrelationship?
Associates/HCRG?
Howdidyouhearaboutourjobposting?
VSAandAssociateWebsite HCRGWebsite Craigslist
Indeed.com Monster CareerBuilder
LinkedIn WorkCompCentral Other(Specify):

EDUCATION
Didyou
College/University YES NO
graduate?
Degree/Diploma/
Major: YearReceived
Certificate
Didyou
College/University YES NO
graduate?
Degree/Diploma/
Major: YearReceived
Certificate
Didyou
College/University YES NO
graduate?
Degree/Diploma/
Major: YearReceived
Certificate
Didyou
College/University YES NO
graduate?
Degree/Diploma/
Major: YearReceived
Certificate

PROFESSIONALLICENSE/CERTIFICATION
License/CertificationTypeandNumber

IssuedbyNumber DateIssued ExpirationDate

License/CertificationTypeandNumber

IssuedbyNumber IssuedbyNumber IssuedbyNumber

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OFFICECOMPUTERSKILLS
Skills Rateyourskillonascaleof110(10beingextremelyproficient) Comments

PersonalComputer

Typing

MicrosoftWord

Excel

DatabaseManagement

Internet

Otherskillsandcomputersoftwareyouarefamiliarwith:

PREVIOUSEMPLOYMENT
Pleaselistyourpresentandmostemployment.Additionalemploymentcanbeattachedinformofaresume.
Company Phone ()

Address Supervisor

JobTitle StartingSalary $ EndingSalary $

Responsibilities

From To ReasonforLeaving

Maywecontactyourprevioussupervisorforareference? YES NO

Company Phone ()

Address Supervisor

JobTitle StartingSalary $ EndingSalary $

Responsibilities

From To ReasonforLeaving

Maywecontactyourprevioussupervisorforareference? YES NO

REFERENCES(Pleaselisttwoprofessionalreferences)
FullName Relationship

Company Position

Phone ()

FullName Relationship

Company Position

Phone ()

VSAandAssociates/HCRG EmploymentApplication Page2 of3

 PLEASEREADCAREFULLY(Ifexplanationisneeded,pleaseprovideitinthebackofthispage)
Ifhired,wouldyouhaveareliablemeansoftransportationtoandfromwork? YES NO

Ifhired,canyoupresentevidenceofyourU.S.citizenshiporproofofyourlegalrighttoliveand
YES NO
workinthiscountry?
Areyouabletoperformtheservicesrequiredbyyouragreement/jobdescriptionwithHCRG,
___withor
___withoutreasonableaccommodation,accordingtoacceptedstandardsofprofessional YES NO
performance

Hasyourprofessionallicense/certificationinanyjurisdictioneverbeendenied,limited,restricted,
suspended,revoked,notrenewed,orsubjecttoprobationaryconditions;or,haveyouvoluntarily,
YES NO
orinvoluntarilyacceptedanysuchactionsorconditions,orhaveyoubeenfinedorreceiveda
letterofreprimandorissuchactionpending?Ifyes,pleaseexplainonthebackofthispage.
Haveyoueverbeenconvictedofacriminaloffense(felonyorseriousmisdemeanor)? Ifyes,please
YES NO
explaininthebackofthispage.
(Note:Noapplicantwillbedeniedemploymentsolelyonthegroundsofconvictionofacriminaloffense.Thenatureoftheoffense,thedateoftheoffense,thesurrounding
circumstancesandtherelevanceoftheoffensetotheposition(s)appliedformay,however,beconsidered.)

Doyoupresentlyuseanydrugsillegally?Ifyes,pleaseexplaininthebackofthispage. YES NO

PLEASEREADCAREFULLY,INITIALEACHPARAGRAPHANDSIGNBELOW
IherebycertifythatIhavenotknowinglywithheldanyinformationthatmightadverselyaffectmychancesfor
______ employmentandthattheanswersgivenbymearetrueandcorrecttothebestofmyknowledge.Ifurthercertify
Initials thatI,theundersignedapplicant,havepersonallycompletedthisapplication.Iunderstandthatanyomissionor

misstatementofmaterialfactonthisapplicationoronanydocumentusedtosecureemploymentshallbegrounds
forrejectionofthisapplicationorforimmediatedischargeifIamemployed,regardlessofthetimeelapsedbefore
discovery.
IherebyauthorizeVSAandAssociates/HCRGtothoroughlyinvestigatemyreferences,workrecord,educationand
______ othermattersrelatedtomysuitabilityforemploymentand,further,authorizethereferencesIhavelistedto
Initials disclosetothecompanyanyandallletters,reportsandotherinformationrelatedtomyworkrecords,without

givingmepriornoticeofsuchdisclosure.Inaddition,IherebyreleasetheCompany,myformeremployersandall
otherpersons,corporations,partnershipsandassociationsfromanyandall
Iunderstandthatnothingcontainedintheapplication,orconveyedduringanyinterviewwhichmaybegrantedor
______ duringmyemployment,ifhired,isintendedtocreateanemploymentcontractbetweenmeandtheCompany.In
Initials addition,IunderstandandagreethatifIamemployed,myemploymentisfornodefiniteordeterminableperiod

andmaybeterminatedatanytime,withorwithoutpriornotice,attheoptionofeithermyselfortheCompany,
andthatnopromisesorrepresentationscontrarytotheforegoingarebindingonthecompanyunlessmadein
writingandsignedbymeandtheCompany'sdesignatedrepresentative.
Shouldasearchofpublicrecords(includingrecordsdocumentinganarrest,indictment,conviction,civiljudicial
action,taxlienoroutstandingjudgment)beconductedbyinternalpersonnelemployedbytheCompany,Iam
entitledtocopiesofanysuchpublicrecordsobtainedbytheCompanyunlessImarkthecheckboxbelow.IfIam
______
Initials
nothiredasaresultofsuchinformation,IamentitledtoacopyofanysuchrecordseventhoughIhavechecked
theboxbelow.


Iwaivereceiptofacopyofanypublicrecorddescribedintheparagraphabove.

ApplicantSignature__________________________________________Date:______________

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