Choices Online Job Application : Choices

Work Experience

Start with your most recent employment. Include any job-related military assignments and volunteer activities. (You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.)

Most recent employer*

Starting/Present Job Title*

Start Date*

End Date

Reason for leaving*

Most recent salary*

Supervisor's Name*

First Name

Last Name

Employer's Address*

City

State

Zip Code

May we contact?* Yes
No

Employer's Phone Number

Work Performed*

List duties. Do not state "see resume".

Previous employer

Starting/Ending Job Title

Start Date

End Date

Reason for leaving

Salary

Supervisor's Name

First Name

Last Name

Employer's Address

City

State

Zip Code

May we contact? Yes
No

Employer's Phone Number

Work Performed

List duties. Do not state "see resume".

Previous employer

Starting/Ending Job Title

Start Date

End Date

Reason for leaving

Salary

Supervisor's Name

First Name

Last Name

Employer's Address

City

State

Zip Code

May we contact? Yes
No

Employer's Phone Number

Work Performed

List duties. Do not state "see resume".

Have you been discharged from any empoyment or asked to resign?* Yes
No

If yes, please explain:

Resume

You may upload a resume in addition to the job application.

Cover Letter

You may upload a cover letter in addition to the job application.

	Personal Information In considering your application for employment, the organization may conduct a detailed and thorough investigation which may include, but is not limited to, a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.
	Name* First Name Middle Name Last Name
	Previous Names Identify all other names under which employed
	Social Security Number*
	Current Address* City State Zip Code
	Permanent Address City State Zip Code
	Home Phone*
	Mobile Phone
	Email Address*
	Best Time to Contact You
	Date Available for Work* Month Day Year
	Position(s) applying for*
	Location(s)*
	Desired Salary*
	Are you applying for: Full Time Part Time Temporary Contract
	How did you learn about us?* Ad Employment agency Friend Relative Job line Walk in Other: Other Value
	Do you have friends or relatives employed by this organization?* Yes No
	List any relatives or friends employed by this organization.
	Have you ever been employed by this or another entity affliated with us?* Yes No
	If yes, please list when and where:
	If you are under 18 years old, can you provide required proof of your eligibility to work?* Yes No
	Are you a US Citizen or alien legally authorized to work in the United States?* Yes No
	Have you ever been convicted of, or plead guilty to, a crime (excluding misdemeanor traffic violations)? * Yes No
	If you answered yes to the above question regarding prior convictions, please explain. If your answer is "yes" to the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.
	Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States? * Yes No
	If you answered yes to the above question regarding abuse, please explain. If your answer is "yes" to the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

	Military Experience
	Were you a member of the US Armed Forces?* Yes No
	Branch
	Dates of duty
	Type of discharge
	Briefly describe duties and any special training:

	Education/Skills
	High School*
	Undergraduate School*
	Course of Study*
	Did you graduate?* Yes No Currently Attending
	Graduation Month Year
	Graduate School
	Course of Study
	Did you graduate? Yes No Currently Attending
	Graduation Month Year
	Professional School
	Course of Study
	Did you graduate? Yes No Currently Attending
	Graduation Month Year
	Specialized Skills Terminal PC/MAC Medical Terminology Spreadsheet Typewriter Shorthand Word Processing Other: Other Value
	Languages, other than English, that you read, write or speak:
	List any professional licenses, registration and certifications you have, including issuing state, date and number:
	Has your professional license ever been suspended, revoked or on probation? Yes No
	If yes, please explain:
	Driver's License Number*
	Driver's License State*
	Has your driver's license ever been suspended, revoked or on probation?* Yes No
	If yes, please explain:
	Other information you feel may be helpful in considering your application:

	Personal/Professional Referecnes Do not include family members or previous supervisors.
	Reference Name* First Name Last Name
	Years known?*
	Reference Phone Number*
	Reference Email Address
	Reference Address City State Zip Code
	Reference Name* First Name Last Name
	Years known?*
	Reference Phone Number*
	Reference Email Address
	Reference Address City State Zip Code
	Reference Name* First Name Last Name
	Years known?*
	Reference Phone Number*
	Reference Email Address
	Reference Address City State Zip Code

	Statement of Application I certify that the information contained in this application (and accompanying resume, if any) is true, correct and complete to the best of my knowledge. I also agree that any falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for termination if discovered at a later date. I authorize a thorough investigation of my past employment, education and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons and/or entities requesting or supplying information from any damages that may result. I authorize Choices, Inc. to request and receive such information. I understand that employment with Choices, Inc. is at-will, which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that Choices, Inc. has the same right. I understand that no one has the authority to alter in any way the at-will nature of employment, except for a written and notarized agreement signed by the chief executive officer of Choices, Inc. If I am employed, I agree to conform to the rules, regulations of Choices, Inc. and I acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by Choices, Inc. at any time at the organization’s sole option and without any prior notice to me. I understand that an offer of employment is contingent upon satisfactory completion/result of the following: a post-offer medical examination (including lab work and drug screening); a reference, background and criminal history check; integrity and/or skills testing; proof of legal authority to work in the United States under federal immigration laws; and completion of the introductory period. I acknowledge being advised that this application will remain active for no more than 6 months from the date it was made. Submission of this application neither automatically results in an employment interview nor a job offer. Choices, Inc. is an Equal Opportunity Employer.
	Signature* First Name Last Name
	Date* Month Day Year
	Applicant's typed name acts as his/her signature

Choices

Choices Online Job Application

Personal Information

Work Experience

Military Experience

Education/Skills

Professional Trade, Business or Civic Activities

Personal/Professional Referecnes

Statement of Application

Confirmation Page

Working for Choices

	Work Experience Start with your most recent employment. Include any job-related military assignments and volunteer activities. (You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.)
	Most recent employer*
	Starting/Present Job Title*
	Start Date* Month Day Year
	End Date Month Day Year
	Reason for leaving*
	Most recent salary*
	Supervisor's Name* First Name Last Name
	Employer's Address* City State Zip Code
	May we contact?* Yes No
	Employer's Phone Number
	Work Performed* List duties. Do not state "see resume".
	Previous employer
	Starting/Ending Job Title
	Start Date Month Day Year
	End Date Month Day Year
	Reason for leaving
	Salary
	Supervisor's Name First Name Last Name
	Employer's Address City State Zip Code
	May we contact? Yes No
	Employer's Phone Number
	Work Performed List duties. Do not state "see resume".
	Previous employer
	Starting/Ending Job Title
	Start Date Month Day Year
	End Date Month Day Year
	Reason for leaving
	Salary
	Supervisor's Name First Name Last Name
	Employer's Address City State Zip Code
	May we contact? Yes No
	Employer's Phone Number
	Work Performed List duties. Do not state "see resume".
	Have you been discharged from any empoyment or asked to resign?* Yes No
	If yes, please explain:
	Resume You may upload a resume in addition to the job application.
	Cover Letter You may upload a cover letter in addition to the job application.