Employment

Employment Application

Personal Information
Name:
Email Address:
Address:
City, State, ZIP:
Home Phone:
Cell Phone:
Work Phone:
Positions Applying For:
Expected Rate Of Pay:
Shift Preferences:
Full-time
Part-time
Volunteer
Day
Evening
Overnight
Weekend
Please make a choice of available hours below:
Monday:
Hours Available
Tuesday:
Hours Available
Wednesday:
Hours Available
Thursday:
Hours Available
Friday:
Hours Available
Saturday:
Hours Available
Sunday:
Hours Available
Are any of your relatives currently employed at Sarah Tuxis?:
 
Yes
No
If Yes, Name & Relationship:
 
Have you ever worked for Sarah Tuxis?:
 
Yes
No
If Yes, Positions & Dates:
Do you possess a valid motor vehicle operator's license?:
 
Yes
No
Type/Class/State:
Do you have current auto insurance in your name?:
 
Yes
No
How did you hear about Sarah Tuxis? (If referred by a current employee, please provide name):
 
In the last seven years have you been convicted of a felony or misdemeanor? :
 
If Yes, Please Describe:
*Conviction will not necessarily bar you from employment with Sarah Tuxis
Certification & Licenses
Have you completed any special courses, seminars, or training that would enable you to preform the position(s) which you are applying for?:
 
Please check any technical or professional licenses you have:
 
First Aid
CPR
PMT
Medication Certification
Other
If other, please detail:
References
Name:
Relationship:
Years Known:
Telephone #:
Name:
Relationship:
Years Known:
Telephone #:
Name:
Relationship:
Years Known:
Telephone #:
Education
Level:
City & State:
Course of study:
Diploma or Degree Attained:
 
Level:
City & State:
Course of study:
Diploma or Degree Attained:
 
Employment
Name of Employer:
Dates of Employment:
Address:
Telephone #:
May we contact?:
Your position/title:
Supervisor's name:
Reason for leaving:
Ending Rate of Pay:
Name of Employer:
Dates of Employment:
Address:
Telephone #:
May we contact?:
Your position/title:
Supervisor's name:
Reason for leaving:
Ending Rate of Pay:
Name of Employer:
Dates of Employment:
Address:
Telephone #:
May we contact?:
Your position/title:
Supervisor's name:
Reason for leaving:
Ending Rate of Pay:
 
Interview Guide
What interests you in working for SARAH Tuxis?:
 
Have you ever done hands-on care before such as bathing, feeding or toileting? If so, in what capacity?:
 
Are you aware of our current payrate?:
 
Where are you working presently?:
 
What is your reason for job change?:
 
How would your supervisor describe you?:
 
What do you think your best qualities are?:
 
What qualities would you like to strengthen or improve?:
 
As per your job description, this job may or may not require you to lift, bend or squat to support a person. Do you have any physical limitations that would prevent you from fulfilling your job duties?:
 
What specific hours & days are you available?:
 
How far are you willing to travel? We have settings on the I-95 corridor from Milford to Old Lyme?:
 
Notification & Agreement
SARAH Tuxis is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, gender, sexual orientation, marital status, national origin, disability, handicap, or veteran status. This application is good for sixty days only. Consideration for employment after 60 days requires a new application.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE; I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) MAY BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

No representative or agent of SARAH Tuxis has the authority to enter into any agreement for employment for any specified period of time other than the Executive Director.

I understand that in order to be eligible for employment, I must be a citizen or a natural of the United States, an alien lawfully admitted for permanent residence,or an alien authorized by the Immigration and Naturalization Service to work in the United States. I further understand that to be employed by SARAH Tuxis, I will be required to present evidence of my identity and employment eligibility that are genuine and relate to me and the Federal Law provides for imprisonment and/or fine for any false statements or use of false documents in connection with my eligibility verification.

I understand as a condition of my employment, I will be subject to a criminal background investigation.

I acknowledge that I have read and understand that above statements and hereby grant permission to confirm the information supplied on this application by me.