FORM JOB APPLICATION LIASIONS COMMUNITY CARE, LLC 21 W COLONY PLACE SUITE 140-B DURHAM, NORTH CAROLINA 27705 PHONE: 919-207-8177 LIASIONS COMMUNITY CARE LLC is equal opportunity employer. This application will not be used for limiting or excluding any application from consideration for employment on a basis prohibited by local, he or she should contact a company representative. Please fill out all of the sections below: Application Information Applicant Name Address City, State and Zip Code Telephone Number Email Address Date of Application Date of Birth Social Security Number Emergency Contact Name / Relationship / Number Employment Position Position(s) applying for How did you hear about this position? What days are you available to work? On what date can you start working if you are hired? Do you have reliable transportation to and from work? YesNo Salary Desired Personal Information Do you have any friends, relatives, or acquaintances working for LIASONS COMMUNITY CARE, LLC? YesNo If yes, state name & relationship Are you 18 years age or older? YesNo Are you a U.S. citizen or approved to work in the United States? YesNo What document can you provide as proof of citizenship or legal status? Will you consent to a mandatory controlled substance test? YesNo Do you have a condition which would require job accommodations? YesNo If yes, please describe accommodations required Have you ever been convicted of a criminal offense (felony or misdemeanor)? YesNo If yes, please state the nature of the crime(s), when and where convicted and disposition of the case (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position (s) applied for may, however, be considered.) Job Skills / Qualifications Please list below the skills and qualifications you possess for the position for which you are applying for: (Note: LIASIONS COMMUNITY CARE, LLC complies with the ADA and considers reasonable accommodations measures that may be necessary for eligible applicants/ employees to perform essential functions.) Education and Training High School Name Location (City, State) Year Graduated Degree Earned College / University Name Location (City, State) Year Graduated Degree Earned Vocational School / Specialized Training Name Location (City, State) Year Graduated Degree Earned Military Are you a member of the Armed Services? YesNo If so, which Armed Services: What branch of the military did you enlist? What was your military rank when you were discharged? How many years did you serve in the military? What military skills do you possess that would be an asset for this position? Previous Employment Employer 1 Employer 2 Employer 3 References Please provide three personal and professional references below: Reference Contact Information Additional Information AT-WILL EMPLOYMENT The relationship between you and the LIASIONS COMMUNITY CARE, LLC is referred to as “employment at will.” This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the LIASIONS COMMUNITY CARE, LLC. No representative of LIASIONS COMMUNITY CARE, LLC has authority to enter into any agreement contrary to the foregoing “employment at will” relationship. You understand that your employment is ” at will” and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company’s President. Applicant Signature (Type Full Name) Date 6+3=?
