Application For Employment

Name*

First Middle Last

Date*

Telephone #:*

Email

Current Address*

Street Address City State ZIP Code

Position Applying For?*

Which Adaptive Indiana location are you applying for?*

Desired Hourly Rate*

Employment desired:*

Full Time
Part Time
Days
Nights

Hours Per Week Preferred:

Have you been previously employed by Adaptive?*

Yes
No

If YES, when?

Are you at least 18 years old?*

Yes
No

Are you a US Citizen, or do you have the legal right to remain and work permanently in the US?*

Yes
No

Do you have adequate means of transportation to get to and from work each day?*

Yes
No

Can you provide a negative TB test in the last 12 months?*

Yes
No

Have you had a Health Assessment/Physical completed by a doctor within the last six months?*

Yes
No

Professional License/Certifications currently held:

HHA
CNA
LPN
RN
Companion / Homemaker

Have you ever had any license revoked, suspended, limited, or not renewed in any state?*

Yes
No

If YES, describe in full:

Have you ever been convicted of a crime?*

Yes
No

If YES, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):

Did you graduate from high school or obtain your GED?*

Yes
No

Employment History

Upload Resume:

Name of Company*

City of Company*

State of Company*

Position Held/Description of type of work*

Previous Pay

Reason for Leaving*

Still Employed
Resignation
Termination
Lay Off

**Adaptive provides equal employment opportunities without regard to race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability. I certify that the information in this application is true and complete for all practical purposes. Should a position be offered and later it is found that any of this information is untrue, incomplete, or misrepresented, I understand and agree that the Adaptive has the right to end my employment. I voluntarily give Adaptive the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within 3 days show satisfactory evidence of identity and eligibility for employment.

Terms and Conditions:*

I understand and acknowledge the terms and conditions as stated above

Signature*

Today's Date:*

Name

This field is for validation purposes and should be left unchanged.

Call 812-590-1575 for more information

Employment Application Form

Employment History