Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
FAX
E-mail

Please provide the following personal identification information:

Date of Birth	mm/dd/yy
Sex	Male Female
SSN

Select any of the following options that apply:

Driver	Homemaker	Administrative staff (receptionists, file clerk, etc.)  

Current or Most Recent Employer:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Third Most Recent Employer:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

List your qualifications for the position(s)) for which you applying:

List Three references we may contact including phone numbers and relationships:

High School Attended:

Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Did you graduate high school?

Please provide the following contact information:

Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone

Number of Years Attended?

Choose one of the following options:

Yes No Presently Attending

Are you legally eligible for employment in the US?

Yes No

When will you be available to work?

-- mm /dd/yy

Have you ever been convicted of a felon? If yes, please explain.

Do you have a valid NM driver's license?

Yes No

By submitting this application, I agree that the information contained herein is true, correct and complete and I understand that false, incomplete or misrepresented information will be sufficient cause for my application being rejected or if I am employed, cause for immediate termination of my employment, regardless of when discovered.

I authorize the employer to contact and obtain information about me from my previous employers. I waive all rights and claims I may otherwise have against CARE-A-VAN, CARE-A-VAN representatives, my previous employers or their representatives for obtaining, providing or using such information.

I understand that this application will expire in 30 days and that I must reapply after this time. I understand that this application is not an employment agreement and that if I do accept an offer of employment, that I will be employed at-will, which means that I may resign at anytime or the employer may terminate my employment at any time without cause and without notice. No one other than the Executive Director has any authority to enter into an employment agreement with terms contrary to the foregoing and must be in writing and properly signed to be valid.

Yes No