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APPLICATION FOR EMPLOYMENT
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Please answer all questions completely. Incomplete applications will not be
considered.
You may attach a resume, but you must still complete the application.
Please list complete addresses, telephone numbers, and names of previous employers.
Prospective employees will receive consideration without discrimination
because of race, creed, color, sex, age, national origin, handicap, sexual orientation,
or veteran status.
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* indicates required field
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Todays Date:
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Personal
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Last Name:
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First Name:
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Middle Initial:
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Social Security Number:
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Address:
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City:
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State:
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Zip Code:
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Previous Address:
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City: |
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State: |
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Zip Code:
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Length of time at current address:
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Length of time at previous address:
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Home Telephone:
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Business Telephone:
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Pager:
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Cellular Telephone:
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Email Address:
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Have you ever applied for employment with us?
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If yes, Please specify month, year, and location.
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Month: |
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Year: |
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Location:
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Position Desired:
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Pay Expected:
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Apart from absences for religious observances,
are you available for full-time work ?
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Are you willing to work weekends and holidays ?
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Will you work overtime if asked ?
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Are you a US citizen or legally eligible for employment in the United States ?
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When will you be available to begin work ?
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If hired, there are certain expenses that may be required, but
may be reimbursable. Are you able to meet this obligation?
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An annual physical examination and TB skin test are required for employment.
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Date of last physical?
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Date of last TB skin test?
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Do you hold a current Arizona driver's license?
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Are you at least 21 years of age? (licensing requirement ):
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Have you been convicted of a crime in the past ten years,
excluding misdemeanors and summary offenses,
which has not been annulled, expunged, or sealed by a Court?
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If "Yes," describe in full :
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State names of relatives and/or friends working for us, other than your spouse:
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Please state below why you are interested in working with La Paloma Family
Services, Inc., and what special qualifications you have to succeed:
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Education
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Graduate School Name:
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Graduate School Location:
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Course of Study:
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# Years Completed:
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Did you graduate?
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What year did you graduate:
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Degree/Diploma:
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Undergraduate School Name: |
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Undergraduate School Location:
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Course of Study:
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# Years Completed: |
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Did you graduate?
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What year did you graduate:
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Degree/Diploma: |
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Business/Trade/Technical School Name: |
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Business/Trade/Technical School Location: |
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Course of Study:
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# Years Completed: |
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Did you graduate?
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What year did you graduate:
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Degree/Diploma: |
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High School Name:
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High School Location:
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Course of Study:
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# Years Completed: |
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Did you graduate? |
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What year did you graduate: |
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Degree/Diploma: |
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Elementary/Middle School Name: |
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Elementary/Middle School Location:
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Course of Study:
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# Years Completed: |
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Did you graduate? |
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What year did you graduate: |
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Degree/Diploma: |
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Special Training or Skills (e.g. languages, machine operation, etc.) |
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Membership in Professional/Civic Organizations
(exclude those that may disclose your race, color, religion, national origin, etc.)
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Employment
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Please give accurate, complete, full-time and part-time employment record. Start
with your present or most recent employer.
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Company Name:
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Address: |
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City: |
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State: |
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Zip Code:
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Telephone Number:
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Supervisor Name: |
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Job Title:
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Description of Duties:
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Employment Dates (month/year):
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From
To:
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Weekly Salary:
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Start:
End:
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Reason for Leaving:
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Company Name:
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Address: |
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City: |
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State: |
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Zip Code:
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Telephone Number:
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Supervisor Name: |
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Job Title:
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Description of Duties:
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Employment Dates (month/year):
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From
To:
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Weekly Salary:
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Start:
End:
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Reason for Leaving:
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Company Name:
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Address: |
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City: |
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State: |
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Zip Code:
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Telephone Number:
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Supervisor Name: |
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Job Title:
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Description of Duties:
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Employment Dates (month/year):
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From
To:
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Weekly Salary:
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Start:
End:
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Reason for Leaving:
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Company Name:
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Address: |
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City: |
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State: |
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Zip Code:
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Telephone Number:
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Supervisor Name: |
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Job Title:
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Description of Duties:
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Employment Dates (month/year):
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From
To:
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Weekly Salary:
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Start:
End:
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Reason for Leaving:
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We may contact the employers listed above unless you indicate those that you do
not wish us to contact :
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DO NOT CONTACT: Employer Name: |
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Reason: |
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DO NOT CONTACT: Employer Name: |
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Reason: |
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Military
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Did/do you serve in the US Armed Forces ?
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If yes, what branch? |
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Describe any training received relevant to the position for which you are applying
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SIGNATURE
� The information provided in this application for employment is true, correct,
and complete.
If employed, any misstatement or omission of fact on this application may result
in dismissal.
� I understand that acceptance of an offer of employment does not create a
contractual obligation upon the employer to continue to employ me in the future.
� If you decide to engage an investigative consumer reporting agency to report
on my credit
and personal history, I authorize you to do so. If a report is obtained you must
provide, at my request,
the name of the agency so that I may obtain from them the nature and substance of
the information contained in the report.
� If this is a web-application, typing my name in the space provided for "Signature"
will serve as my handwritten signature.
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*
Signature: |
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Date: |
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ATTACHMENT A
LA PALOMA FAMILY SERVICES, INC.
APPLICANT AVAILABILITY FORM
This sheet is your opportunity to be specific about the days and hours you are available
to work.
Please make and list your hours of availability in the appropriate spaces below.
Please be accurate, as this sheet assists in achieving proper shift coverage.
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Are you available to work on Monday's? |
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If yes, what hours?
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Are you available to work on Tuesday's? |
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If yes, what hours?
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Are you available to work on Wednesday's? |
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If yes, what hours?
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Are you available to work on Thursday's? |
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If yes, what hours?
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Are you available to work on Friday's? |
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If yes, what hours?
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Are you available to work on Saturday's? |
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If yes, what hours?
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Are you available to work on Sunday's? |
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If yes, what hours?
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*
Signature: |
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Date: |
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