PRE- EMPLOYMENT APPLICATION

PLEASE PRINT IN INK OR TYPE. APPLICATION MUST BE FULLY COMPLETED ( ON BOTH SIDES) FOR CONSIDERATION.
Date: _______________ Type of work desired (Application will be filed under 1 st choice):
1st choice: _________________________________________

2nd choice: ______________________________________________

Name: ___________________________________________________

Social Security Number: ____________________________

Address: ______________________________________ City: ______________ Zip:___________ Phone: (

) ______________

Person to contact in case of emergency: Name: ___________________________________________ Phone: (

) ______________

Work Preference: Full Time

Part Time

Relief

Per Diem

Shift Preference: Day

Evenings

Nights

Have you ever worked or applied at Mt. San Antonio Gardens before?
Worked: Yes

No

If yes, when? ______________________

Applied: Yes

No

If yes, when? _______________

How were you referred to this organization for employment? __________________________________________________________

BACKGROUND DATA
1.

Do you have a legal right to work in the United States?............................................................ Yes

2.

Are you 18 years of age or older? ............................................................................................. Yes

3.

No
No

If under 18, can you (if offered employment) provide a work permit? ........................................................... Yes

No

Have you ever been convicted of a crime? .............................................................................. Yes

No

If yes, please explain: ________________________________________________________________________________

(PLEASE NOTE: A conviction will not necessarily disqualify you from employment. Each case will be considered on its own
merits.)
4.

Are you related to any of our employees? ............................................................................... .Yes

No

If yes, please give their name(s): _______________________________________________________________________

5.

On what date will you be available for work? ________________________________________________

EMPLOYMENT IS CONTINGENT ON THE ABILITY TO PASS A PHYSICAL EXAMINATION AND A DRUG AND
ALCOHOL SCREEN, PROVIDE ACCEPTABLE REFERENCES, AND SUBMIT PROOF OF IDENTITY AND LEGAL
ABILITY TO WORK IN THE UNITED STATES.
Mt. San Antonio Gardens is an equal opportunity employer. It is our policy to recruit, hire and promote for all job classifications on
the basis of merit, qualifications and competence. All employment decisions will be based on the individuals qualifications related
to requirements of the positions being filled. Mt. San Antonio Gardens will hire only individuals who are legally able to work in
the United States.
PLEASE COMPLETE THE
REVERSE SIDE OF
THIS APPLICATION.

This section must be completed, even if supplemented by a resume. Beginning with the present, list all jobs during the past ten years.
Include military service and unemployment.
Dates of
Employment

Company Name and Address

Phone Number

Supervisor

Title and /or Duties

From:___________________________________________________________________________________________________
To: _____________________________________________________________________________________________________
Salary: _______________ Reason for Leaving:
Dates of
Employment

____________________________________________________________

Company Name and Address

Phone Number

Supervisor

Title and /or Duties

From:___________________________________________________________________________________________________
To: _____________________________________________________________________________________________________
Salary: _______________ Reason for Leaving: ____________________________________________________________
Dates of
Employment

Company Name and Address

Phone Number

Supervisor

Title and /or Duties

From:___________________________________________________________________________________________________
To: _____________________________________________________________________________________________________
Salary: _______________ Reason for Leaving:

_____________________________________________________________

PERSONAL REFERENCES: (DO NOT list employers or relatives. Provide all requested information for three references.)
Name
Address
Phone Number
________________________________

______________________________________________________________________

__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________ ______________________________________________

_____________________

EDUCATIONAL RECORD:
Name

City/State

# of Years
Completed

Major

Diploma or
Degree

Last High School: _.................................................................................................___________

___________________ _______________
____________ _______________
College/University
____________ _.............................................................................................................................................................______________
Additional Education:
Professional Registry and/or License Number: .. State: .. Expiration Date: .
Foreign Languages: I read: . I speak: I write:
I understand any misrepresentation or material omission of information in this application or health service medical record will be cause for
denial of employment or for dismissal if employed. I authorize all former employers, companies, agencies and persons contacted to release
any and all information in their possession which has or may have bearing on my suitability for employment. I understand a physical
examination which includes a drug and alcohol screen by Mt. San Antonio Gardens physician will be required prior to my employment. I
agree to and understand the above statements. I hereby certify that all the information included on this application is true to and complete to
the best of my knowledge. I understand that employment at Mt. San Antonio Gardens is at the mutual consent of employer and employee,
and that the employment relationship can be terminated by either party. Mt. San Antonio Gardens is a non-smoking facility.

Signature: ______________________________________________________________

Date: ____________________________ _