Creating A New Start in Recovery, Inc.

Employment Application
(Company Name) is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from
consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable
accommodation in the application andor inter!iew process should notify a representati!e of the organi"ation.
Please print and fill out all sections.
Applicant Information
Applicant Name ########################################################################
$ocial $ecurity % ############################### &ate of 'irth #############################
Address ##############################################################################
City ################################ $tate ##################### (ip Code ###############
)ome % ####################### Cell % ######################## *ther % ###################
+mail Address #########################################################################
)ow long ha!e you been at the abo!e address, ########## day(s) month(s) year(s) (circle one)
)ow did you hear about (C*-.AN/ NA-+),
friend######internet#####employee#######otther###############################
Potential Employment Information
Type of .osition(s) ######################################################################
0hat type of wor1 would you accept, (circle all that apply)
permanent part2time##### permanent full2time ##### temporary part2time####### temporary full2time####
0hat days and hours are you a!ailable for wor1,
$un ####### -on ####### Tue ####### 0ed ####### Thurs ####### 3ri ####### $at #######
4f hired, on what date can you start wor1ing, ########################
Can you wor1 on the wee1ends, ###/es### No, +!enings, ###/es### No, *!ertime, ###/es## No
&esired $alary5 6############# per hour wee1 year (circle one)
Personal Information

EMPLOYEE SIGNATURE DATE
pg. 7
Creating A New Start in Recovery, Inc.
)a!e you e!er applied to or wor1ed for (C*-.AN/ NA-+), ##### /es ##### No
4f yes, please explain (include date)5 #######################################################
&o you ha!e any friends, relati!es, or acquaintances wor1ing for (C*-.AN/ NA-+), ##### /es #####
No
4f yes, state name 8 relationship5 ##########################################################
4f hired, would you ha!e transportation to and from wor1, #####/es #####No
&ri!er9s :icense % ################### $tate of issue ################# +xp. &ate #############
&o you ha!e proof of insurance, #####/es #####No
)a!e you had any accidents or mo!ing !iolations during the past three (;) years, ####/es ()ow many, %
####) ####No
Are you o!er the age of 7<, (4f under 7<, hire is sub=ect to !erification of minimum legal age.) #####/es ###No
4f hired, would you be able to present e!idence of your >.$. citi"enship or proof of your legal right to wor1 in
the >nited $tates, ##### /es ##### No
)a!e you e!er been con!icted of a criminal offense (felony or misdemeanor), #####/es #####No
4f yes, please describe the crime2state nature of the crime(s), when and where con!icted and disposition of
the case ##############################################################################
Skills and Training:
:ist and attach documentation for all current training and certifications you ha!e completed5





List and attach documentation for all current licenses held:


List any professional associations of which you are a member:


Education

EMPLOYEE SIGNATURE DATE
pg. ?
Creating A New Start in Recovery, Inc.
Check highest level completed. 12 GED College 1 2 3 4
Graduate chool 1 2 3 4
School Location
Attende
d
From To
rad!
Type o"
#egree
or
#iplom
a
$a%or $ino
r
)igh $chool @+&

YES
NO
College>ni!ersity

YES
NO
@raduate of .rofessional
$chool


YES
NO
Aocational Technical
$chool

YES
N&
Business References
:ist three (;) persons who ha!e 1nowledge of your wor1 performance within the last four (B) years oter tan
relati!es"
Name %7######################################### .hone % #############################
*ccupation ############################## Cnown for5 ######## /ears ######## -onths
Name %? ######################################### .hone % #############################
*ccupation ############################## Cnown for5 ######## /ears ######## -onths
Name %; ######################################### .hone % #############################
*ccupation ############################## Cnown for5 ######## /ears ######## -onths

Employment #istory

EMPLOYEE SIGNATURE DATE
pg. ;
Creating A New Start in Recovery, Inc.
'elow, please describe your past and present employment positions, dating bac1 fi!e years. .lease account for all periods of
unemployment. +!en if you ha!e attached resume9, this attachment must be completed. (state your most current first)
Name of +mployer %7 ###########################################Name of $uper!isor #########################
Telephone % ##################:ength of +mployment (include dates) from ########### to##########
.osition ############## $tatus full2time part2time (how many hours per wee1) %
.opulation $er!ed Adults D Children D
&uties and Eesponsibilities


Eeason for :ea!ing #####################################################################
-ay we contact this employer for references, #####/es #####No
Name of +mployer %? ###########################################Name of $uper!isor #########################
Telephone % ##################:ength of +mployment (include dates) from ########### to##########
.osition ############## $tatus full2time part2time (how many hours per wee1) %
.opulation $er!ed Adults D Children D
&uties and Eesponsibilities


Eeason for :ea!ing #####################################################################
Name of +mployer %; ###########################################Name of $uper!isor #########################
Telephone % ##################:ength of +mployment (include dates) from ########### to##########
.osition ############## $tatus full2time part2time (how many hours per wee1) %
.opulation $er!ed Adults D Children D
&uties and Eesponsibilities


Eeason for :ea!ing #####################################################################
Note:$$$Add Additional seet if needed
Signature Page for Employment Application
Please read and initial eac paragrap% ten sign &elo'

EMPLOYEE SIGNATURE DATE
pg. B
Creating A New Start in Recovery, Inc.
4 certify that 4 ha!e not purposely withheld any information that might ad!ersely affect my chances for hiring.
4 attest to the fact that the answers gi!en by me are true 8 correct to the best of my 1nowledge and ability
to understand that any omission (including and misstatement) of material fact on this application or on any
document used to secure can grounds for re=ection of application or 4 am employed by his company terms
for my immediate expulsion from the company. ######### (initials)
4 permit the company to examine my references, record of employment, education record, and any other
information 4 ha!e pro!ided. 4 authori"e that references 4 ha!e listed to disclose any information related to
my wor1 record and my professional experiences with them, without gi!ing me prior notice of such
disclosure. 4n addition, 4 release the company, my former employers 8 all other persons, corporations,
partnerships 8 associations from any 8 all claims, demands of liabilities arising out of or in any way related
to such examination or re!elation. ######### (initials)
Applicant9s $ignature5 ######################################### &ate5 ###################
)uman Eesource9s $ignature5 #################################### &ate5 #################
3or *ffice >se *nly
4nter!iew &ate5 #########################
Eeferences Chec1ed 'y5 ######################################
)ire &ate5 #########################

EMPLOYEE SIGNATURE DATE
pg. F