admin – moremirs

Moremi Residential Services

Inclusion | Empowerment | Independence

5904 Thoreau Ave

260-435-9402

ayodeji@moremirs.com

NEW EMPLOYEE APPLICATION FORM

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT, but is merely intended to evaluate suitability for employment purposes only. It is the policy of Moremi Residential Services LLC to provide equal employment opportunities to all qualified persons without discrimination based on sex, race, color, religion, age, marital status, nationality, citizenship, sexual orientation, veteran status, or any other status protected under State and Federal Law. It is also the policy of Moremi Residential Services LLC to conduct pre-employment screening before making a job offer. If a job offer is made, employment may be contingent upon successful completion of a medical examination, which may also include the collection of bodily specimens through a facility-approved laboratory.

PERSONAL INFORMATION

Last Name

First Name

Middle Name:

Date of Birth:

Social Security #:

Cell Phone:

Home Phone:

Email Address

Position Applied For:

Date Available:

Desired Pay Rate:

Full Time Part Time Either

PLEASE LIST YOUR CURRENT ADDRESS AND YOUR PAST TWO ADDRESSES

Current Address: Street:

City:

State:

Zip Code:

Since (Mo/Yr):

Past Address 1: Street:

City:

State:

Zip Code:

Since (Mo/Yr):

Past Address 2: Street:

City:

State:

Zip Code:

Since (Mo/Yr):

Undergraduate / College:

College Name:

City/State:

From:

To:

Graduated

Yes No

Area of Study:

Degree/Certificate Obtained:

Graduate School:

School Name:

City/State:

From:

To:

Graduated

Yes No

Area of Study:

Degree/Certificate Obtained:

EMPLOYMENT INFORMATION

Please answer all of the following questions. When necessary, note the question number and use an extra sheet of paper to provide more details.

Are you at least 18 years of age and legally eligible to work in the United States?

Yes No

Will you work overtime when necessary?

Yes No

Do you understand the job requirements for the position you are applying for?

Yes No

Are you currently bound by a non-competition or trade secret agreement?

Yes No

If yes, please explain:

Have you ever been discharged or asked to resign from a job?

Yes No

If yes, please explain:

Have you ever been convicted of or pleaded guilty to a felony or any other crime that has not been expunged, sealed, or dismissed?

Yes No

If yes, please explain:

Are you able to perform the essential functions of the job with or without reasonable accommodation?

Yes No

Do you have reliable transportation to and from work?

Yes No

EMPLOYMENT HISTORY

May we contact your previous employer?

Yes No

Please list your last three employers, beginning with the most recent.
Most Recent Employer:

Employer Name:

City/State:

Zip:

Employer Phone:

From:

To:

Position Held:

Supervisor Name:

Reason for Leaving:

Former Employer 1:

Employer Name:

City/State:

Zip:

Employer Phone:

Position Held:

From:

To:

Supervisor Name:

Reason for Leaving:

Former Employer 2:

Employer Name:

City/State:

Zip:

Employer Phone:

Position Held:

From:

To:

Reason for Leaving:

Please answer all of the following questions. When necessary, note the question number and use an extra sheet of paper to provide more details.

Do you have a valid Driver's License? If yes —

Yes No

Driver's License Number:

State:

Exp. Date:

Have you ever been convicted of or pleaded guilty to any traffic-related offense in the past 5 years?

Yes no

If yes, please explain:

Has your driver's license ever been suspended, revoked, or modified by a court of law?

Yes no

If yes, please explain:

Are you CPR Certified?

Yes No

Are you Core A Certified?

Yes NO

Are you Core B Certified?

Yes NO

Do you have experience working with adults or children with physical and/or intellectual disabilities?

Yes No

If yes, please describe:

Please use this space to list any special skills, training, or workshops attended that are relevant to the position applied for:

Please list any professional licenses, designations, or certifications that may relate to the position applied for (e.g., Crisis Intervention, Medication Management, HHA, CNA, etc.). Include the date granted, issuing organization, and any other relevant information:

License/Certification 1

License/Certification 2:

License/Certification 3:

License/Certification 4:

REFERENCES

Please list three individuals who can attest to your character, work ethic, and ability to work with a diverse population. Please include at least one professional reference. Do not list family members.

Reference 1:

Name:

Relationship

Phone :

Email :

Years Known

Reference 2:

Name:

Relationship

Phone :

Email :

Years Known

Reference 3:

Name:

Relationship

Phone :

Email :

Years Known

APPLICANT'S CERTIFICATION AGREEMENT

Please read all statements carefully before signing.

I understand that I may be required to submit a copy of my resume, and that by submitting a resume, I understand that it will be used as only supporting and additional background information. A resume is not an authorized substitute for a completed employment application.
I understand that if I choose to complete only a portion of the required employment application, the information submitted may be inadequate from which to base an employment determination, and as a result, my application may not receive full consideration.
I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information. I also release Moremi Residential Services LLC from all liability that may result from making background investigations.
I certify that the facts and information outlined in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application or on any required documents will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.
I agree to conform to all existing and future workplace rules, regulations, policies, and procedures of Moremi Residential Services LLC if I am offered and accept a position.
I understand and agree that Moremi Residential Services LLC reserves the right to change any wage, hours of work, or working conditions at its sole discretion, at any time, as deemed necessary.
I understand that any employment offer is contingent upon my providing proof of identity and eligibility to work in the United States within 3 days of my start date, in conformance with the provisions of the Immigration Reform and Control Act of 1986.
I understand that any employment offer is contingent upon my providing proof of identity and eligibility to work in the United States within 3 days of my start date, in conformance with the provisions of the Immigration Reform and Control Act of 1986.

Applicant's Signature:

Date

Applicant's Signature:

Date

NEW EMPLOYEE PAYROLL CHECKLIST

Full Name:

Hire Date:

Gender:

Date of Birth:

Social Security #

Street Address:

City / State / Zip Code:

Telephone

Email Address:

Marital Status:

Number of Exemptions:

Additional Money Withheld:

Garnishment / Child Support:

Employment Type:

Full Time Part Time

Pay Rate:

Direct Deposit Information:

Name of Bank:

Account Number:

Confirm Account Number:

Routing Number:

Account Type:

Checking Savings

Author name: admin

Hello world!

Moremi Residential Services

PERSONAL INFORMATION

PLEASE LIST YOUR CURRENT ADDRESS AND YOUR PAST TWO ADDRESSES

Undergraduate / College:

Graduate School:

EMPLOYMENT INFORMATION

EMPLOYMENT HISTORY

Please list your last three employers, beginning with the most recent.
Most Recent Employer:

Former Employer 1:

Former Employer 2:

Please list any professional licenses, designations, or certifications that may relate to the position applied for (e.g., Crisis Intervention, Medication Management, HHA, CNA, etc.). Include the date granted, issuing organization, and any other relevant information:

REFERENCES

APPLICANT'S CERTIFICATION AGREEMENT

NEW EMPLOYEE PAYROLL CHECKLIST

Direct Deposit Information:

Author name: admin

Hello world!

Moremi Residential Services

NEW EMPLOYEE APPLICATION FORM

PERSONAL INFORMATION

PLEASE LIST YOUR CURRENT ADDRESS AND YOUR PAST TWO ADDRESSES

Undergraduate / College:

Graduate School:

EMPLOYMENT INFORMATION

EMPLOYMENT HISTORY

Please list your last three employers, beginning with the most recent. Most Recent Employer:

Former Employer 1:

Former Employer 2:

Please list any professional licenses, designations, or certifications that may relate to the position applied for (e.g., Crisis Intervention, Medication Management, HHA, CNA, etc.). Include the date granted, issuing organization, and any other relevant information:

REFERENCES

APPLICANT'S CERTIFICATION AGREEMENT

NEW EMPLOYEE PAYROLL CHECKLIST

Direct Deposit Information:

Please list your last three employers, beginning with the most recent.
Most Recent Employer: