MALIBU HEALTH CARE AGENCY, INC.

(An Equal Opportunity Employer)

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

Date: ___________

Name:_______________________________ SSN#: ____________ Birth Date: __________

(Last)
(First)
Address: ____________________________________________________________________
(Street)

(City)

(State)

Phone Number: (
)______ _______ Message(other) Phone #: (
Marital Status: ____________________

Emergency Contact: _____________________ Phone: (

(Zip)

)_____ ___________

) ______________________

EMPLOYMENT
Position applied for __________ Date Available ____________ Days Available M T W T F S S / Same Day
Assignments Y_ N_
Do you have use of an automobile? _____ Are you on a Bus Line? ______ Salary Required
____________
Do you have Current Auto Insurance? ______ Name of Company: _________________
Policy #:______________
(Please submit a copy of the current Auto Insurance Policy)
Have you ever been convicted of a felony? ______
if yes, please explain:__________________________________
_____________________________________________________________________________________________________

EDUCATION HISTORY
Last grade completed: 6 7 8 9 10 11 12
Name of High School___________________________
Location_____________________________________
Last year completed in College/ Trade School: 1 2 3 4
Name of College/Trade School____________________
Location______________________________________

Are there any experiences, special skills, of qualifications which you feel qualify you to work for MALIBU
HEALTH CARE AGENCY INC?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
REFERENCES
List two (2) Personal and/or professional references:
Name: _________________________________
Address: ______________________________

Relationship: __________________________
Phone (
) _____________ Years known _____

Name: _________________________________
Address: ________________________________

Relationship: ___________________________
Phone (
) _____________ Years known _____

EMPLOYMENT HISTORY
List Below your last (5) employers starting with the present job. There may be periods in that you
were not employed please explain.
Employer: ______________________________ Address: _________________________________
Date Employed: Month: __________ Year: _______ to Month: __________ Year_________
Please explain any period you were not employed. Month: ______ Year: ______
Reason?_________________________________________________________________________
Immediate Supervisor: _______________ Company Phone # :(
) _________________________
Job Title: _____________________________
Duties/Responsibilities:__________________________________________________________________
Final Wage: _____________ Was Separation Voluntary or Involuntary: _____________ Reason: ______
Employer: ______________________________ Address: _________________________________
Date Employed: Month: __________ Year: _______ to Month: __________ Year_________
Please explain any period you were not employed. Month: ______ Year: ______
Reason?_________________________________________________________________________
Immediate Supervisor: _______________ Company Phone # :(
) _________________________
Job Title: _____________________________
Duties/Responsibilities:__________________________________________________________________
Final Wage: _____________ Was Separation Voluntary or Involuntary: _____________ Reason: ______
Employer: ______________________________ Address: _________________________________
Date Employed: Month: __________ Year: _______ to Month: __________ Year_________
Please explain any period you were not employed. Month: ______ Year: ______
Reason?_________________________________________________________________________
Immediate Supervisor: _______________ Company Phone # :(
) _________________________
Job Title: _____________________________
Duties/Responsibilities:__________________________________________________________________
Final Wage: _____________ Was Separation Voluntary or Involuntary: _____________ Reason: ______

Employer: ______________________________ Address: _________________________________

Date Employed: Month: __________ Year: _______ to Month: __________ Year_________
Please explain any period you were not employed. Month: ______ Year: ______
Reason?_________________________________________________________________________
Immediate Supervisor: _______________ Company Phone # :(
) _________________________
Job Title: _____________________________
Duties/Responsibilities:__________________________________________________________________
Final Wage: _____________ Was Separation Voluntary or Involuntary: _____________ Reason: ______
Employer: ______________________________ Address: _________________________________
Date Employed: Month: __________ Year: _______ to Month: __________ Year_________
Please explain any period you were not employed. Month: ______ Year: ______
Reason?_________________________________________________________________________
Immediate Supervisor: _______________ Company Phone # :(
) _________________________
Job Title: _____________________________
Duties/Responsibilities:__________________________________________________________________
Final Wage: _____________ Was Separation Voluntary or Involuntary: _____________ Reason: ______
As an applicant for employment with MALIBU HEALTH ACRE AGENCY INC., I understand the following:
Certify that the facts contained in this application are true and complete to the best of my
knowledge and understand that, if employed; falsified statements on this application shall be
grounds for dismissal.
Understand that under conditional offer of employment I am required to submit to the preemployment drug and alcohol screening. The results of such testing may be ground for
withdrawing the offer or employment.
I must meet the employability requirements of Federal Immigration Law and submit appropriate
documentation to satisfy the requirements for completing INS form I-9
If my application for employment is accepted, the effective date of my employment may be
time I actually begin to work. If I accept the employment, I agree to comply with and be bound
by the safety and health rules and regulations and rules of conduct of MALIBU HEALTH CARE
AGENCY INC. Altogether with obligations set forth in the company policies.
All information (including information on any accompanying resume) is correct and will be
subject y verification
Will you authorize MHCA. To contact each of your previous employer(s) and references Yes__
No__ State which of your previous employers you do not want us to contact and give us the
reason why
Employer: ______________________ Reason:_____________________________________
Signature:_____________________________

Date: _____________________________

_______________________DO NOT WRITE BELOW THIS LINE_________________________

Check List Office Use
Date

Score

Date Taken

Expiry Date

Competency

__________

_____

Hire Date:__________
Position: __________
Will Report to:_________________
Wage:__________

Ph/Exam _________
PPD
_________
Driver Lic. _________
Professional Lic/Cert _________
First Aid _________
CPR
_________
Appearance: [ ] Good [
Disposition: [ ] Good [
Experience: [ ] Good [
Flexibility: [ ] Good [
Speech/Communication: [ ] Good [

__________
__________
__________
__________
__________
__________
] Fair [ ] Poor
] Fair [ ] Poor
] Fair [ ] Poor
] Fair [ ] Poor
] Fair [ ] Poor

Comments:___________________________________________________________________________
Approved (1) _____________________________

___________________________________

(Administrative Assistant)

(2) _____________________________________
(Chairman/CEO)

___________________________________