Job application form template



JOB APPLICATION FORM

|Position applied for: |

|Given name: |Last name: |

|Address: |

| |

|Email: |

|U.S. Citizenship: |

| |

|Are you a United States citizen? Yes No |

|(If no, are you authorized to work in the U.S?) Yes No |

|Current qualifications |

|Qualification title |Institution/training provider |Year completed |

| | | |

| | | |

| | | |

|Are you currently undertaking study/training? | |Yes | |No |

|(tick one) | | | | |

|If yes, course/program name: |

|(tick one) | |Full time | |Part time | |Distance | |Other |

|Previous employment (most recent first) |

|Employer name/ |Dates from/to |Position held |Reason for leaving |Office use |

|establishment | | | |check |

| | | | |initial/date |

| | | | | |

| | | | | |

| | | | | |

| | |Yes | |No |

|Do you agree to have referees contacted in relation to this application? (tick one) | | | | |

|(Reference checks will be conducted legally in an ethical manner and all information derived will remain confidential.) |

|Please provide details of three people who can speak on your behalf regarding your work history. |

|Name |Contact No. |Position held/working relationship |Office use |

| | |(eg supervisor) |check |

| | | |initial/date |

| | | | |

| | | | |

| | | | |

|What type of work are you available for? |Full time | |Part time | |Casual | |

|(tick one) | | | | | | |

|When will you be available for work? | |

|Please provide any other information that you identify as being pertinent to this application |

|(eg medical conditions, disabilities) |

| |

| |

| |

|VOLUNTARY INFORMATION SECTION |

|Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any |

|individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, |

|because of such individual’s race, color, religion, sex, or national origin. |

| |

| |

|This employer is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the|

|employer to invite employees to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary and refusal|

|to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in|

|accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the |

|information to be summarized and reported to the Federal Government for civil rights enforcement purposes. If you choose not to |

|self-identify your race/ethnicity at this time, the federal government requires this employer to determine this information by visual |

|survey and/or other available information. For civil rights monitoring and enforcement purposes only, all race/ethnicity information |

|will be collected and reported in the seven categories identified below. The definitions for each category have been established by the|

|federal government. If you choose to voluntarily self-identify, you may mark only one of the boxes presented below. |

| |

| |

| |

|Gender: ( Female ( Male |

|Race: ( American Indian or Alaskan Native ( Asian or Pacific Islander ( Black ( White ( Hispanic ( Combination of Two or |

|More Races (if checked supply the code the attached list: Code:________ |

|Person with a disability: ( Yes If yes, do you need accommodations during the application for admission process? ( Yes If |

|yes, please describe the accommodations needed. |

| |

|Person who is an English language learner or limited English proficient: ( Yes If yes, do you need language assistance during |

|the application for admission process? ( Yes If yes, please describe the assistance needed. |

Declaration

I declare that, to the best of my knowledge, the information given is true and correct. I understand that inaccurate, misleading or untrue statements or knowingly withheld information may result in termination of employment with this organisation. I understand that this application does not constitute an offer of employment. I understand that, in some cases, police and credit checks will be required and I will be notified if this applies to this application.

|Signed: |Date: |

CONFIDENTIAL

VIKO Health Services

Background Check Authorization

Print Name:

| |(First) |(Middle) |(Last) | | | |

|Former Name(s) and Dates Used: | | | | | |

|Current Address Since: | | | | | | | |

| | |(Mo/Yr) | |(Street) | |(City)| |(Zip/State) | |

|Previous Address From: | | | | | | | |

| | |(Mo/Yr) | |(Street) | |(City)| |(Zip/State) | |

|Previous Address From: | | | | | | | |

| | |(Mo/Yr) | |(Street) | |(City)| |(Zip/State) | |

|Social Security Number: | | | | | |Date of | |

| | | | | | |Birth: | | |

Drivers License Number: ________________________________State: _________

The information contained in this application is correct to the best of my knowledge. I hereby authorize (Organization Name) and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to (Organization Name) or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I hereby release (Organization Name), the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

Signature: ___________________________ Date: ______________

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