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How did you hear about us?	Self Initiated Job Service - Which state? Newspaper - Name of paper? Job or Career Fair - Which one? Employee Referral - Name of employee? Internet - Website?
Please explain your answer above:
Contact Information
Name/Co:	*
Email:	*
Phone#:	*
Alternate#:
Address:
City / State / Zip:
SSN:

Position(s) you are applying for:
Pay Requested:	HourlySalary
Type of employment desired:	Full TimeTemporary Part TimeOn-call/PRN
Shift Preference:	1st2nd3rdWeekendsSplit Shift
Will you work overtime if required?	YesNo
If No, please explain:
If you are under 18 and it is required, can you furnish a work permit?	N/AYesNo
Are you a citizen of the United States?	YesNo
If not, Have you received employment authorization from the Immigration and Naturalization Service to work in the US?	YesNo

Have you ever been employed with Fahrney-Keedy Memorial Home, Inc. before?	YesNo
If Yes, When?

Have you ever filed an application with Fahrney-Keedy Memorial Home, Inc. before?	YesNo
If Yes, When?

Are you able to perform each of the essential functions of the job for which you are applying, with or without accommodation?(see job description, Here).	YesNo
(You may be asked to describe or demonstrate how you will be able to perform these functions, with or without accommodation.)

Have you ever been convicted of a crime, other than a minor traffic offense?	YesNo
If Yes, Explain:
(Answering “Yes” does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.)

Education Information
High School Name:
High School Location:
Graduated:	YesNo
If No, Highest Grade Completed:

College Name:
College Location:
Degree/Certificate:	YesNo
Course Studied:

Other - Trade or Vocational School Training:
Other Location:
Course Studied:

Describe any other training, courses of study, or skills acquired (including License #, Type, Expiration and Place of issue).


Employment History
Report all employers in the past 10 years.

Company Name:
Supervisor Name:
Address:
City / State / Zip:
Phone Number:
Dates Employed:	to xx/xx/20xx
Are you still working for this company?	YesNo
May we contact this employer?	YesNo
Job Title:
Hourly Rate / Salary: Starting:
Hourly Rate / Salary: Final:
Describe your job duties:
Reason For Leaving:

Company Name:
Supervisor Name:
Address:
City / State / Zip:
Phone Number:
Dates Employed:	to xx/xx/20xx
Are you still working for this company?	YesNo
May we contact this employer?	YesNo
Job Title:
Hourly Rate / Salary: Starting:
Hourly Rate / Salary: Final:
Describe your job duties:
Reason For Leaving:

Company Name:
Supervisor Name:
Address:
City / State / Zip:
Phone Number:
Dates Employed:	to xx/xx/20xx
Are you still working for this company?	YesNo
May we contact this employer?	YesNo
Job Title:
Hourly Rate / Salary: Starting:
Hourly Rate / Salary: Final:
Describe your job duties:
Reason For Leaving:

Company Name:
Supervisor Name:
Address:
City / State / Zip:
Phone Number:
Dates Employed:	to xx/xx/20xx
Are you still working for this company?	YesNo
May we contact this employer?	YesNo
Job Title:
Hourly Rate / Salary: Starting:
Hourly Rate / Salary: Final:
Describe your job duties:
Reason For Leaving:

Company Name:
Supervisor Name:
Address:
City / State / Zip:
Phone Number:
Dates Employed:	to xx/xx/20xx
Are you still working for this company?	YesNo
May we contact this employer?	YesNo
Job Title:
Hourly Rate / Salary: Starting:
Hourly Rate / Salary: Final:
Describe your job duties:
Reason For Leaving:

References
Provide three business references from previous jobs (for example, former supervisor) that are not related to you. If you have not worked before, please give three other references.

Name:
Address:
Phone:

Name:
Address:
Phone:

Name:
Address:
Phone:


Certification, Acknowledgement and Consent

1. I hereby certify that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I further certify that I have not withheld any facts of information that, if disclosed, could affect my application unfavorably. I understand that false, misleading, or incomplete information in this application and/or in my interview(s) will void this application or subject me to discharge at any time, if I am employed.

2. I expressly acknowledge and understand that in the absence of a written contract to the contrary, my status, if I am hired, will be that of an employee at will having no contractual right, expressed or implied, to remain in Fahrney-Keedy Memorial Home, Inc.’s employ. In this connection, I expressly acknowledge further that neither anything said to me during Fahrney-Keedy Memorial Home, Inc.’s application and/or interview process or during employment nor any provision in Fahrney-Keedy Memorial Home, Inc.’s policies or employee manual constitutes the terms of an expressed or implied employment agreement. In consideration of any employment offered, I specifically agree that my employment may be terminated, with or without cause or notice, at any time, and the option of either Fahrney-Keedy Memorial Home, Inc. or myself. I understand that no unauthorized representative may enter into any agreement contrary to the foregoing.

3. I expressly authorize Fahrney-Keedy Memorial Home, Inc. to contact my prior employer(s) and current employer, references I have named in this employment application, and such other persons or entities as they may deem to have relevant information, including a criminal background check, for the purpose of investigating my background, and I expressly agree that information form each of these sources may be used by Fahrney-Keedy Memorial Home, Inc. in considering this application. I also hereby permit each of these sources to disclose to Fahrney-Keedy Memorial Home, Inc. information in their possession or subject to their control, including information contained in my personnel file(s). In this regard, I expressly agree to sign whatever forms Fahrney-Keedy Memorial Home, Inc. reasonably requires, including appropriate authorization forms, so that it may contact these sources and obtain relevant information about me. Finally, I expressly release Fahrney-Keedy Memorial Home, Inc. from any and all liability of whatever kind and nature which, at any time, may result from obtaining, and making an employment decision based upon, the requested information.

4. If I am hired and my employment terminates for any reason, Fahrney-Keedy Memorial Home, Inc. may answer all questions asked by a prospective employer concerning my abilities and employment record, and I release Fahrney-Keedy Memorial Home, Inc. from any and all liability that may result from its responding to any such questions.

5. I expressly acknowledge and agree that if employment with Fahrney-Keedy Memorial Home, Inc. is offered, may be contingent upon -- if required, in Fahrney-Keedy Memorial Home, Inc. sole discretion and to the extent permitted by law -- my completion, with favorable results, of a pre-employment examination and/ or substance abuse screening test.

6. NOTICE TO APPLICANT: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT ANY INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. ANY EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

By agreeing below, I confirm that I have read and understand each of the certifications, acknowledgements, and consents set forth above.

Type your full name here:
Date:	xx/xx/20xx

VOLUNTARY EEO IDENTIFICATION
Various agencies of the United States Government require employers to maintain information on applicants pertaining to factors such as race, sex, and type of position for which an individual applies. The information requested, on this sheet, is for compliance with certain record keeping requirements and will not be used in determining an applicant's abilities. The Company believes all persons are entitled to equal employment opportunities and does not discriminate against it employees or applicants for employment because of race, color, Gender, religion, national origin, disability, veteran status, age, marital status or any other protected group status.

Position Applying for:
Gender:	MaleFemale


Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, North Africa or the Middle East Black (Not Hispanic or Latino) - A person having origins in any of the Black racial groups of Africa Native Hawaiian or other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islanders Asian (Not Hispanic or Latino) - A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam American Indian or Alaskan Native(Not Hispanic or Latino) - A person having origins in any of the original peoples of North or South America (Including Central America), and who maintains tribal affiliation or community recognition Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races

Regulations issued by the U.S. Department of Labor with respect to disabled individuals, disabled veterans, and Vietnam Era veterans require that federal contractors provide an opportunity for self-identification to candidates seeking employment. Such self-identification is submitted on a voluntary basis, on a confidential basis, for use only in accordance with regulations, and without subjecting the individual to adverse treatment.

Disabled/Veteran Classification(s):
Disabled Person - Federal regulations define a disabled person as one who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (2) has a history of such impairment, or (3) is regarded as having such an impairment. Vietnam Era Veteran - Federal regulations define a veteran of the Vietnam Era as one who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964, and May 7, 1975. Special Disabled Veteran (30% or more disability) - Federal regulations define a special disabled veteran as one who (1) is entitled to compensation under laws administered by the Veterans’ Administration for a disability rated 30% or more, or (2) was discharged or released from active duty because of a service-connected disability.

AN EQUAL OPPORTUNITY EMPLOYER
Referred by:NewspaperTelevisionFriend who is employed by F.K.M.H.Other


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Contact Information

Education Information

Employment History

References

Certification, Acknowledgement and Consent