APPLICATION FOR EMPLOYMENT
YOUNG AT HEART An Equal Opportunity Employer
Last Name
First Name
MI
Date of Birth
Social Security Number
mm/dd/yyyy
Street Address
City
Home Phone
Cell Phone
123-123-4567
000-00-0000
State
Zip Code
E-Mail Address
123-123-4567
Date You Can Start
Shift/Hours Desired
Total Hours Per Week
Morning (6:00-12:00)
Evening (6:00-12:00)
Afternoon (12:00-6:00)
All
Hours
Select ALL that apply
Position Desired
Wage/Salary Desired
$
Mon
Type of Employment Desired
Per Hour
Your Availability For Work (Please indicate AM/PM see example)
Tue
Wed
Thu
Fri
Sat
Sun
From
To
Example
1:00pm
9:00am
10:30am
6:00am
12:00pm
High School Attended
City
Education Background
State Diploma
College Attended
City
State
Graduate
6:15am
4:30pm
GED
Presently Enrolled
List Any Job Related Skills or Accomplishments, Please Include Military Service (350 character limit)
APPLICATION FOR EMPLOYMENT
YOUNG AT HEART An Equal Opportunity Employer
Provide Three References That Are NOT Former Employers or Family Members We May Contact
Name & Occupation
How Do You Them & For How Long?
Phone Number
Employment History
List Employers from MOST RECENT go back 10 years or past three employers
(1) Employer Name
Job Title
Address
City
Supervisor Name
(2) Employer Name
State
Phone Number
Zip Code
Supervisor Name
(3) Employer Name
Supervisor Name
Starting Pay
Ending Pay
$
$
Job Title
State
Phone Number
Zip Code
Start Date
End Date
Starting Pay
Ending Pay
$
$
Reason For Leaving
Job Title
Address
City
End Date
Reason For Leaving
Address
City
Start Date
State
Phone Number
Zip Code
Start Date
End Date
Starting Pay
Ending Pay
$
$
Reason For Leaving
If hired can you provide evidence of legal eligibility to work in the U.S?
Have you ever been convicted of a felony or a misdemeanor involving any violent act, use or possession
of a weapon, or act of dishonesty for which the record has not been sealed or expunged or do you have
such a case pending?
APPLICATION FOR EMPLOYMENT
YOUNG AT HEART An Equal Opportunity Employer
If convicted or case pending when?
If convicted or case pending where?
CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM
I certify that all of the information provided in this employment application is true and complete to the
best of my knowledge, and I authorize investigation of all statements contained in this application,
including a criminal background check and drug test. I understand that any false or incomplete
information may disqualify me from further consideration for employment and may result in my
immediate discharge if discovered at a later date.
I understand and acknowledge that unless otherwise defined by applicable law or written agreement
with Young At Heart Inc. (YAH), any employment relationship with YAH is considered “employment at
will.” This means the Employee may resign at any time and the Employer may discharge the Employee
at any time, with or without cause, and with or without advance notice.
I authorize the investigation of any or all statements contained in this application and also authorize any
person, school, current employer, past employers, and other organizations to provide information
concerning my previous employment and other relevant information that may be useful in making a
hiring decision. I release such persons and organizations from any legal liability in making such
statements.
I have read, understand, and agree to the above statements.
Please check the box and insert you initials below to acknowledge your agreement.
Initials
Date