Employment Application

Applicant Information

Applicant Full Name: Home Address:

Number of years at this address:

Driver's License (State/Number):

Emergency Contact

Who should be contacted if you are involved in an emergency?

Contact Name: Relationship to you: Address:

Job Details

Position Applied For:

Who referred you to our company? Do you have any friends or relatives who work here? If yes, please list here: Have you applied to our company previously? YesNo If yes, when? Are you at least 18 years old? YesNo How will you get to work? Are you willing to work any shift, including nights and weekends? YesNo If no, please state any limitations: If applicable, are you available to work overtime? YesNo If you are offered employment, when would you be available to begin work? If hired, are you able to submit proof that you are legally eligible for employment in the United States? YesNo Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation? YesNo What reasonable accommodation, if any, would you request?

Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

First

Employer Name: Supervisor Name: Address:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Second

Employer Name: Supervisor Name: Address:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Third

Employer Name: Supervisor Name: Address:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

References

List any two non-relatives who would be willing to provide a reference for you.

First References

Name: Address:

Telephone:

Relationship:

Second References

Name: Address:

Telephone:

Relationship:

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize REKINDLE SUPPORTED LIVING LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to communicate information fully and freely regarding my previous employment, attendance, and grades. I authorize those persons designated as references to communicate information fully and freely regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Manager, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of REKINDLE SUPPORTED LIVING LLC, except in a specific written contract of employment signed on behalf of the organization by its Manager, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.