• First Name:

• Last Name:

• Phone:

Night Phone:

Cell Phone:

• Email:

• Address:

• City:

• State:

• Zip:

• Discipline/Type:

• Have you worked or attended school under any other names?

If yes, please list for reference checking purposes

• Are you legally authorized to work in the U.S.?
(If hired, proof of work authorization will be required)

• Are you at least 18?
If not, your employment will be subject to verification that you meet state/federal minimum age requirements for the type of work you are applying for and have a valid work permit.

• Have you ever been convicted of a crime or pleaded no contest for any offenses other than minor traffic violations?

If yes, please explain the nature of the crime, the date of conviction, and state in which convicted: (convictions are not an automatic bar to employment)

• Any pending criminal charges against you?

If yes, describe the nature of the charges,
the date issued and the county and state where issued:

• Have you ever applied at MJ Care, Inc. before?

If yes, date:

• Have you ever worked at MJ Care, Inc. before?

• How were you referred to MJ Care?

• Position applying for:

• Position type:

• Salary preference:

• Setting desired:

• State Desired:

• When can you start?

Day

Month

Year

Service Branch:

Highest Rank:

Entry Date:

Discharge Date:

List the professional license(s) you currently hold.
(Please include license number as well):

• High School

Name

City

State

Major

Diploma/Degree

College/University

Name

City

State

Major

Diploma/Degree

Year Graduated

Graduate School

Name

City

State

Major

Diploma/Degree

Year Graduated

Other

Name

City

State

Major

Diploma/Degree

Year Graduated

(Supervisors/Professor/Colleague, no relatives or personal friends)

• Name:

• Relationship:

• Title:

• Day Phone:

• Company Name:

• How long has this person known you?

• Name:

• Relationship:

• Title:

• Day Phone:

• Company Name:

• How long has this person known you?

• Name:

• Relationship:

• Title:

• Day Phone:

• Company Name:

• How long has this person known you?

(Please start with your most recent employer)

• Employer Name:

• Address:

• Phone:

• Job Title:

• Salary Start:

Salary End:

• Reason for Leaving:

• Supervisor Name:

• Employed From:

• Employed To:

• May we contact as a reference?

• Description of Duties:

Employer Name:

Address:

Phone:

Job Title:

Salary Start:

Salary End:

Reason for Leaving:

Supervisor Name:

Employed From:

Employed To:

May we contact as a reference?

Description of Duties:

Employer Name:

Address:

Phone:

Job Title:

Salary Start:

Salary End:

Reason for Leaving:

Supervisor Name:

Employed From:

Employed To:

May we contact as a reference?

Description of Duties:

Employer Name:

Address:

Phone:

Job Title:

Salary Start:

Salary End:

Reason for Leaving:

Supervisor Name:

Employed From:

Employed To:

May we contact as a reference?

Description of Duties:

MJ Care, Inc. is committed to the employment and advancement of minorities, women, individuals with disabilities and veterans. If you fall into one of these protected classifications, we invite you to identify yourself and receive coverage under our company's Affirmative Action Plan. You may inform us of your desire to benefit under the program at this time and/or anytime in the future.

Completion of this form is voluntary and in no way effects the decision regarding your employment opportunity. The information provided will beheld in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts.

Employee Name:

Sex:

Position applying for:

Race/Ethnic Group:

How were you referred to this job:

Government contractors/subcontractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam era and qualified disabled individuals.

Disabled Veteran
A "Disabled Veteran" is a person entitled to disability compensation under laws administered by the Veterans Administration for a disability rated at 30% or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

Veteran of the Vietnam Era
A "Veteran of the Vietnam Era" is a person who served on active duty for more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged with other than a dishonorable discharge. Veterans meeting the above criteria who served in the Republic of Vietnam between February 28, 1961 and May 7, 1975 are also protected.

Disabled Individual
A "Disabled Individual" is defined as an individual who has a mental or physical impairment which substantially limits one or more major life activities, has a record or such impairment, or who is perceived as having such an impairment.

If you are an individual with a disability, we would like to include you under the Affirmative Action Program. It would assist us if you tell us about (1) any special methods, skills and procedures which qualify you for the positions that you might not otherwise be able to do because of your disability so that you will be considered for any positions of that kind, and (2) the accommodations necessary to assist you in performing the job properly and safely, including special equipment, changes in the physical layout of the job, elimination of certain duties relating to the job, provision of person assistance services, or other accommodations.

1. All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired.

2. I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment.

3. I understand that upon receiving a job offer, a TB Skin Test screening, drug screening, criminal check and motor vehicle report may be required.

4. Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company's, unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed, written document.

• I understand and agree to these terms - CHECK THIS BOX  

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