* Required Information
APPLICATION FOR EMPLOYMENT

Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veterans’ employment. We are an equal opportunity employer

PERSONAL INFORMATION
Name
Present Address
Permanent Address
In Case of Emergency Notify
EMPLOYMENT DESIRED
PROFESSIONAL LICENSES, CERTIFICATION, AND REGISTRATIONS
License / Certificate / Registration Number Type State Issue Date Expires Status (List Active, Inactive, Restricted, Conditional or Pending)
REFERENCES

Give below the names of three work related references.

NAME ADDRESS COMPANY/POSITION PHONE
EDUCATION

NAME AND LOCATION OF SCHOOL YEARS ATTENDED GRADUATED DEGREE/CERTIFICATION
HIGH SCHOOL
COLLEGE
COLLEGE
ADDITIONAL TRAINING
FORMER EMPLOYERS

List below your complete employment history for the last five years, starting with the most recent position first. Attach additional pages if necessary.

DATE MONTH AND YEAR (FROM) DATE MONTH AND YEAR (TO) NAME AND ADDRESS OF EMPLOYER SUPERVISOR'S NAME SALARY POSITION REASON FOR LEAVING

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection or dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without cause, and with or without any prior notice.

VOLUNTARY SELF-IDENTIFICATION INFORMATION

AMERICAN FAMILY CARE LLC is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age, handicap, marital status, source of income, class, physical characteristics, sexual orientation or political beliefs.

As an employer, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please complete this Voluntary Self-Identification Information form. This data is for analysis and affirmative action only and submission of this information is voluntary. This data will be kept in a confidential file separate from your Application for Employment.

Gender:
• Male
• Female
• Choose not to respond 		Veteran Status:
• Vietnam era veteran
• Disabled veteran
• Other veteran
• Non-veteran
• Choose not to respond
Race/Ethnic Background:
• American Indian / Alaskan Native
• Asian
• Native Hawaiian/ Other Pacific Islander
• Black / African or African American
• Hispanic / Latino
• White / Caucasian
• Two or More Races
• Choose not to respond
Disability Status*:
• Disabled
• Not disabled
• Choose not to respond

* According to the American with Disabilities Act, the term “disability” means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of that individual, a record of such an impairment, or being regarded as having such an impairment

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