Handmaker Application

Please Read Carefully and Type Your Name Above to Acknowledge

HJSA is an equal opportunity employer, and selects individuals best matched for the job based upon job-related qualifications regardless of race, religion, color, creed, sexual orientation, national origin, age, disability, or any other status or characteristic protected by law.

I certify that all statements contained in this application (including attachments, if any) are true to the best of my knowledge. If HJSA, during it’s investigation, or later if I am employed, discovers that statements have been omitted or are false or misleading, I understand that I may receive no further consideration for employment and that this may be grounds for dismissal. My electronic signature above authorizes all current and prior employers, educational institutions and branches of the United States Armed Services, whether listed above or not, to furnish HJSA with complete information concerning my employment, academic transcripts, and service records. The information requested may include inquiries regarding my work habits, other related activities, abilities, character, and the cause of my separation.

I hereby authorize HJSA to investigate my personal history and to obtain from my previous employers or personal references any information they have concerning me. I am hereby informed that as part of the employment procedure, an investigative consumer report may be made whereby information is obtained through mail, telephone and personal interviews with previous employers, personal references, friends and/or others with whom I am acquainted or have been employed. This inquiry, if made, may include information as to my character, general reputation, personal characteristics and work habits. I understand that HJSA may be requesting information concerning my motor vehicle operation history and criminal history from various states, private and insurance sources along with other public records available. Further, I understand I have the right to make a written request within reasonable time to receive additional detailed information about the nature and scope of any investigation that is made. I am fully aware and understand that my employment may be subject to meeting HJSA standards with respect to an employment screening and/or an employment substance abuse test. If employed, I understand that such employment is at will, and as such is for no specific duration and may be terminated at any time with or without cause.

I release each of the above references and HJSA and authorized representatives from any liability for damages, which might result from the furnishing of or the use of any of this information. I understand that completion of this application does not indicate that there are any positions open and does not obligate this company to hire me or offer me a job.

In consideration of my employment, I agree to conform to the rules and regulations of HJSA.

Handmaker Jewish Services for the Aging is an equal opportunity employer. No discrimination is made against any individual in any phase of employment in accordance with local, state and federal laws.

Date:
Name:
Phone:
Street Address:
City,State,Zip:
Email Address:
What type of position are you applying for?
Are you currently employed?	Yes No
Have you ever been an employee of Handmaker?	Yes No
If yes, when? (provide dates of employment)
Are you at least 18 years old? (if under 18, hire is subject to verifications of minimum legal age)	Yes No
Were you referred to Handmaker by one of our employees?	Yes No
If yes, whom?
Which shifts are you able to work?	Days Evenings Nights
How often would you like to work?	Full Time Part Time Per Diem
What days and hours are you available to work?
Are you legally eligible for employment in the United States?	Yes No
If employed, can you provide proof of U.S. Citizenship, or proof of your right to live and work in the U.S.?	Yes No
If you are applying for a position that requires driving, please indicate if you have had traffic violations.	Yes No
If yes, please explain:
Have you ever been convicted of either a felony(s) or misdemeanor(s)? Or, do you have any adjudication pending?	Yes No
If yes, please list ALL charges that resulted in a conviction or are still pending (no application will be barred employment solely on the basis of conviction of a criminal offense):
If hired, would you have a reliable means of transportation to and from work?	Yes No
Are you able to perform the essential functions of the job for which you are applying?	Yes No Not Sure
If no, describe which functions can't be performed - NOTE - HJSA complies with the ADA and considers reasonable accommodation measures that may be necessary for applicants/employees to perform essential job functions:
Please list all professional licenses & certificates (i.e. RN, LPN, CNA, Caregiver). Please note: All certificates must be provided at time of hire. Please list by TYPE/LICENSE NUMBER/EXPIRAION DATE:
Has your professional license ever been suspended or revoked?	Yes No Does Not Apply
If yes, please explain:
Please indicate skills and/or training that would enhance your qualifications:
High School/GED - please provide name of school, location, your name during attendance, years completed:
Did you graduate?	Yes No
Technical or Nursing School - please provide name of school, location, your name during attendance, years completed:
Did you graduate?	Yes No
If yes, what degree did you receive/area of study?
College or University - please provide name of school, location, your name during attendance, years completed:
Did you graduate?	Yes No
If yes, what degree did you receive/area of study?
Graduate School - please provide name of school, location, your name during attendance, years completed:
Please list degree/area of study:
Please list three (3) persons not related to you whom you have known for at least one (1) year. Please list by name/occupation/phone number:
May we contact your current employer?	Yes No Does not apply
Current Employer (including military service) - Company Name, Phone Number, Position Held, Supervisor Name, Brief Description of Duties, Dates of Employment, Reason for Leaving, Salary:
Previous Employer (including military service) - Company Name, Phone Number, Position Held, Supervisor Name, Brief Description of Duties, Dates of Employment, Reason for Leaving, Salary:
Previous Employer (including military service) - Company Name, Phone Number, Position Held, Supervisor Name, Brief Description of Duties, Dates of Employment, Reason for Leaving, Salary:
Previous Employer (including military service) - Company Name, Phone Number, Position Held, Supervisor Name, Brief Description of Duties, Dates of Employment, Reason for Leaving, Salary:
Previous Employer (including military service) - Company Name, Phone Number, Position Held, Supervisor Name, Brief Description of Duties, Dates of Employment, Reason for Leaving, Salary:
Please read the information provided at the bottom of this page. Your typed name serves as your signature and states you have carefully read and acknowledge the statement below: