Careers Form

* = Required Information

Elohim Staffing Agency, Inc. is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Applicant Information

Applicant Name *

Address *

City *

State *

Zip Code *

Telephone Number: *

Email *

SSN *

DOB *

Date of Application *

Employment Application

How did you hear about this position?

What days are you available for work?

What hours or shift are you available for work?

If needed, are you available to work overtime?

Yes

On what date can you start working if you are hired?

Do you have reliable transportation to and from work?

Salary desired:

Personal Information

Have you ever applied to or worked for Elohim Staffing Agency, Inc. before?

Yes

When?

Are you 18 years of age or older?

Yes

Are you a U.S. citizen or approved to work in the United States?

Yes

What document can you provide as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?

Yes

Do you have any condition which would require job accommodations?

Yes

If yes, please describe accommodations required below

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Elohim Staffing Agency, Inc. complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

Education and Training

High School

Name

Location (City, State)

Year Graduated

Degree Earned

College/University

Name

Location (City, State)

Year Graduated

Degree Earned

Vocation and Training

Name

Location (City, State)

Year Graduated

Degree Earned

Previous Employment

Employer Name

Job Title

Supervisor Name

Employer Address

City

State

Zip Code

Employer Telephone

Dates Employed

Reason for leaving

References

Please provide 2 personal and professional reference(s) below:

Name

Contact Information

Name

Contact Information

Additional Information

AT - WILL EMPLOYMENT

The relationship between you and the Elohim Staffing Agency, Inc. is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Elohim Staffing Agency, Inc.. No representative of Elohim Staffing Agency, Inc. has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at - will employment status, except for a written statement signed by you and either our Executive Vice - President/Chief Operations Officer or the Company's President.

Applicant Signature

Dated

R.N	L.P.N	C.M.A	C.N.A
H.H.A	Interpreter