How Did You Hear About Us: 

  Self Initiated
  Job Service/Which state:
  Newspaper/Name of paper:
  Job or Career Fair/Which one:
  Employee Referral/Name of employee:
  Internet/Website: 
 

Personal Information

Name:
Address:
City: State:   Zipcode:
Phone:                         Cell/Other        
Email Address:

SSN:  Provide Later

Position(s) you are applying for:
Pay Requested:    Hourly Salary

Type of employment desired: Full Time  Part Time  Temporary  On-call/PRN

Shift Preference: 1st    2nd    3rd    Weekends    Split Shift

Will you work overtime if required? Yes   No
If No, please explain:

If you are under 18 and it is required, can you furnish a work permit? N/A  Yes  No

Are you a citizen of the United States? Yes  No  If not, Have you received employment authorization from the Immigration and Naturalization Service to work in the United States? Yes  No

Have you ever been employed with Fahrney-Keedy Memorial Home, Inc. before?  Yes  No
If Yes, When?

Have you ever filed an application with Fahrney-Keedy Memorial Home, Inc. before?  Yes  No
If Yes, When?

Are you able to perform each of the essential functions of the job for which you are applying, with or without accommodation? (see job description, Here). Yes  No (You may be asked to describe or demonstrate how you will be able to perform these functions, with or without accommodation.)

Answering “Yes” to the following question does not constitute an automatic bar to employment.  Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever been convicted of a crime, other than a minor traffic offense? Yes  No  
If Yes, Explain

Education

High School:
Name   Location
Graduated Yes  No    Highest Grade Completed

College:
Name   Location
Course Studied
Degree/Certificate Yes  No

Other - Trade or Vocational School Training:
Name   Location
Course Studied
Degree/Certificate Yes  No

Describe any other training, courses of study, or skills acquired (including License #, Type, Expiration and Place of issue

Employment History
Report all employers in the past 10 years.

Company Name:
Supervisor Name:
Address:
City: State:   Zipcode:
Phone Number:
Dates Employed: to   xx/xx/20xx
Are you still working for this company? Yes  No
May we contact this employer?   Yes  No
Job Title:
Hourly Rate / Salary: Starting   Final
Describe your job duties:
Reason For Leaving:
 

Company Name:
Supervisor Name:
Address:
City: State:   Zipcode:
Phone Number:
Dates Employed: to   xx/xx/20xx
Job Title:
Hourly Rate / Salary: Starting   Final
Describe your job duties:
Reason For Leaving:

 

Company Name:
Supervisor Name:
Address:
City: State:   Zipcode:
Phone Number:
Dates Employed: to   xx/xx/20xx
Job Title:
Hourly Rate / Salary: Starting   Final
Describe your job duties:
Reason For Leaving:

 

Company Name:
Supervisor Name:
Address:
City: State:   Zipcode:
Phone Number:
Dates Employed: to   xx/xx/20xx
Job Title:
Hourly Rate / Salary: Starting   Final
Describe your job duties:
Reason For Leaving:

 

Company Name:
Supervisor Name:
Address:
City: State:   Zipcode:
Phone Number:
Dates Employed: to   xx/xx/20xx
Job Title:
Hourly Rate / Salary: Starting   Final
Describe your job duties:
Reason For Leaving:

References

Provide three business references from previous jobs (for example, former supervisor) that are not related to you. If you have not worked before, please give three other references.

Name:
Address:
Phone:

Name:
Address:
Phone:

Name:
Address:
Phone:

Certification, Acknowledgement and Consent

Type your full name here:   Date:   xx/xx/20xx

VOLUNTARY EEO IDENTIFICATION 

Position Applying for:

Gender:  Male  Female

Ethnicity:

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race

Race:
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, North Africa or the Middle East;
Black (Not Hispanic or Latino) - A person having origins in any of the Black racial groups of Africa;
Native Hawaiian or other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islanders;
Asian (Not Hispanic or Latino) - A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam;
American Indian or Alaskan Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North or South America (Including Central America), and who maintains tribal affiliation or community recognition;
Two or More Races (Not Hispanic or Latino) - All Person who identify with more than one of the above five races

Regulations issued by the U.S. Department of Labor with respect to disabled individuals, disabled veterans, and Vietnam Era veterans require that federal contractors provide an opportunity for self-identification to candidates seeking employment. Such self-identification is submitted on a voluntary basis, on a confidential basis, for use only in accordance with regulations, and without subjecting the individual to adverse treatment.

Disabled/Veteran Classification(s):

Disabled Person - Federal regulations define a disabled person as one who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (2) has a history of such impairment, or (3) is regarded as having such an impairment.
Vietnam Era Veteran - Federal regulations define a veteran of the Vietnam Era as one who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964, and May 7, 1975.
Special Disabled Veteran (30% or more disability) - Federal regulations define a special disabled veteran as one who (1) is entitled to compensation under laws administered by the Veterans’ Administration for a disability rated 30% or more, or (2) was discharged or released from active duty because of a service-connected disability.

AN EQUAL OPPORTUNITY EMPLOYER

Referred by:  Newspaper    Television  Friend who is employed by F.K.M.H.  Other.

Note: Please only click the submit button once. If you attached a resume file it may take additional time to upload the file to us. Clicking submit more than one time may cause the page to error.

You will be forwarded to another page once the form submission is completed.