EDUCATIONAL BACKGROUND<= o:p>

HIGH SCHOOL:&nbs= p; &= nbsp; ______________________________________= ________________

ADDRESS: &n= bsp; = ; &n= bsp; Street___________________________City __________________

State_______________Zip________________

DIPLOMA/G.E.D.&n= bsp; = ; = YES = = NO

COLLEGE: &n= bsp; = ; &n= bsp; ______________________________________________________

ADDRESS: &n= bsp; = ; &n= bsp; Street___________________________City __________________

State_______________Zip________________

DEGREE/MAJOR:&nb= sp; = ______________________DIPLOMA RECEIVED: YES <= /span>NO

GRADUATE: &= nbsp; &nbs= p; _____= ________________________________________________

ADDRESS: &n= bsp; = ; &n= bsp; Street___________________________City _________________

State_______________Zip________________

DEGREE/MAJOR:&nb= sp; = ______________________ DIPLOMA RECEIVED: YES = = NO

OTHER: &nbs= p; &= nbsp; &nbs= p; _____________________________= _________________________

ADDRESS: &n= bsp; = ; &n= bsp; Street___________________________City __________________

State_______________Zip________________

DEGREE/MAJOR:&nb= sp; = ______________________ DIPLOMA RECEIVED: YES = = NO

PREVIOUS EXPERIENCE

Have you ever applied to this agency for a job b= efore? = 9Yes = 9No

If yes, when? ____________________

Have you ever worked for this agency before? = 9Yes 9No &n= bsp; If so, when?______________

Have you any experien= ce working with persons who are mentally

disabled or elderly? = ; 9Yes = 9No

If yes, explain: &= nbsp; __________________________________________________= ________________

_____________________= _________________________________________________________=

ADDITIONAL QUALIFICATIONS<= /p>

<= /span>

Specialized Skills: &= nbsp; ________= ______________________________________________

(please list) &= nbsp; &nbs= p; _________________= _____________________________________

= &nb= sp; = _______= _______________________________________________

Related Volunteer &= nbsp; ________= ______________________________________________

Experience: = ; &n= bsp; = ; ______________________________________________________=

&nbs= p; &= nbsp; &nbs= p; &= nbsp; __________________________________________________= ____ &= nbsp;

EMPLOYMENT HISTORY (BEGIN WITH MOST RECENT)

ACCOUNT FOR ALL EMPLOYMENT FOR THE LAST 10 YEARS.

1. &n= bsp; Employer: &= nbsp; __= ____________________________________________________

Address: &n= bsp; = ; Street__________________= _________City__________________

State__________________Zip____________Phone____________

Position: &= nbsp; &nbs= p; ______________________________________________________=

<= span style=3D'mso-tab-count:3'> &= nbsp; &nbs= p; = From:____________ To:________________ &= nbsp;

&nbs= p; &= nbsp; &nbs= p; 9Full Time &= nbsp; 9Part Time &= nbsp; 9Per Diem &n= bsp; &n= bsp; = ; &n= bsp;

Duties: &nb= sp; = _______= _______________________________________________

Supervisor: &= nbsp; ______________= ________________Salary:__________________

Reason for leaving: ______________________________________________________

2. &n= bsp; Employer: &= nbsp; __= ____________________________________________________

Address: &n= bsp; = ; Street__________________= _________City__________________

State__________________Zip____________Phone____________

Position: &= nbsp; &nbs= p; ______________________________________________________=

<= span style=3D'mso-tab-count:3'> &= nbsp; &nbs= p; = From:____________ To:________________ &= nbsp;

&nbs= p; &= nbsp; &nbs= p; 9Full Time &= nbsp; 9Part Time &= nbsp; 9Per Diem

Duties: &nb= sp; = _______= _______________________________________________

Supervisor: &= nbsp; ______________= ________________Salary:__________________

Reason for leaving: ______________________________________________________

3. &n= bsp; Employer: &= nbsp; __= ____________________________________________________

Address: &n= bsp; = ; Street__________________= _________City__________________

State__________________Zip____________Phone____________

Position: &= nbsp; &nbs= p; ______________________________________________________=

<= span style=3D'mso-tab-count:3'> &= nbsp; &nbs= p; = From:____________ To:________________ &= nbsp;

&nbs= p; &= nbsp; &nbs= p; 9Full Time &= nbsp; 9Part Time &= nbsp; 9Per Diem

Duties: &nb= sp; = _______= _______________________________________________

Supervisor: &= nbsp; ______________= ________________Salary:__________________

Reason for leaving: ______________________________________________________

4. &n= bsp; Employer: &= nbsp; __= ____________________________________________________

Address: &n= bsp; = ; Street__________________= _________City__________________

State__________________Zip____________Phone____________

Position: &= nbsp; &nbs= p; ______________________________________________________=

<= span style=3D'mso-tab-count:3'> &= nbsp; &nbs= p; = From:____________ To:________________ &= nbsp;

&nbs= p; &= nbsp; &nbs= p; 9Full Time &= nbsp; 9Part Time &= nbsp; 9Per Diem

Duties: &nb= sp; = _______= _______________________________________________

Supervisor: &= nbsp; ______________= ________________Salary:__________________

Reason for leaving: ______________________________________________________

EMPLOYMENT AUTHORIZATION

I certify that ans= wers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary= in arriving at an employment decision. I hereby release those persons supplying such employment and backgro= und information from any liability whatsoever from their actions in supplying s= uch information. I understand that neither this document nor any offer of employment from the employer constit= ute an employment contract unless a specific document to that effect is execute= d by the employer and employee in writing.

<= /span>

I understand that employment with Mercy Haven is subject to driver’s license check and fingerprinting, if applicable. I understand that after meeting all other job prerequisites, and after I am m= ade a conditional offer, employment will be contingent upon the satisfactory outcome of reference requests. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in withdrawal of conditi= onal offer of employment or discharge. I understand that I am required to abide by all rules and regulations of the = employer.

_____________________= _____________________ &= nbsp; &nbs= p; &= nbsp; __________________

Signature &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Date=

FORM OF AUTHORIZATION FOR RELEASE OF INFORMATION

As a condition of my employment, I authorize Mercy H= aven, Inc., or their agents to conduct the following investigative reports:

Driver License Che= ck

Applicant’s Signature:___________________________________Date:____________________=

Please answer the questions below as completely as possible. Let us know your thoughts. Why

do you want this position? Why d= o you feel that you would be qualified for this position?

_________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= ___________________________________________________________________________= __________________________________________________________________________<= /p>

________________________________= ______________________________________________

DOC:L:DOCUMENT\HRESOURC\FORMS\EMPAPPL

REVISED 04/07/06