6. Professional Licenses, Registrations, or Certifications
Type, State Issued, Expiration Date, and No.
7. Military Service (if applicable)
8. Employment history, starting with most recent
Please list 3 professional references, if different than employment history
Full name, Relationship, Company, Phone #
Thank you for completing this application form and for your interest in working with us. A Rosie Place adheres to a policy of equal employment opportunity. All employment decisions are made without regard to race, religion, age, sex, color, national origin or handicap and in full compliance with all federal and state laws. Your opportunity for employment with us is based on your merit, past experience and your ability to perform the job. Further, any offer of employment may be conditioned upon the results of a medical examination, including a screening procedure of illegal drugs, which will occur before you begin work.
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I authorize A Rosie Place to investigate my background and to confirm information contained in this application and I release A Rosie Place and/or any other person, organization or institution from any and all liability that may result from any investigation into my background conducted by A Rosie Place.
I understand that misrepresentation or omission of facts on this application or any other A Rosie Place records will cause for rejection of my application or my immediate discharge should I be subsequently employed. Further, I accept that nothing in this application or in granting of an interview implies or should be understood as a promise of employment. Also, I understand that should I be subsequently employed by A Rosie Place I have the right to terminate my employment at any time and that A Rosie Place may at its discretion terminate at any time with or without cause.
Thank you for your application!