New Application Form - Kids In Motion

General Information
Full Name*
First Name Last Name
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
If hired, can you furnish proof you are eligible to work in the U.S.?*
- Yes
- No
Are you at least 18 years of age or older?*
- Yes
- No
Have you ever worked in the healthcare field?*
- Yes
- No
If yes, when & where

Employment History Information
Work History: Current and previous 2 employers (most current employer listed first)
Most Recent Employer
City, State
Position Held
Start Date
Month
Day
Year
Date Finished
Month
Day
Year
Employer phone
Supervisor name
First Name Last Name
Describe your duties:
Reason for leaving
NEXT EMPLOYER
Employer's Name
City, State
Position Held
Start Date
Month
Day
Year
Date Finished
Month
Day
Year
Employer phone
Supervisor name
First Name Last Name
Describe your duties:
Reason for leaving

Additional Information
Have you ever been convicted of a felony?*
- Yes
- No
If yes, please give date and explain
Have you ever been employed under a name other than the name used on this application?*
- Yes
- No
If yes, please explain

I understand and agree that, if hired my employment is "at will" and is not for a definate period and may, regardless of circumstances, be terminated at any time without prior notice by the Company. I further acknowledge that no contract of employment will be valid against the company unless signed by the president of the Company.

I acknowledge that as a condition of my employment, I will be required to agree to be bound by the terms of and sign the Company. Failure to sign this Agreement shall result in revocation of my offer of employment.
Choose ONE:*
- I accept
- I do not accept

Reference 1: