ACHIEVING SMILES WAIVER SERVICES Name * First Name Last Name DOB MM DD YYYY SS# Address Address 1 Address 2 City State/Province Zip/Postal Code Country HOME (###) ### #### CELL (###) ### #### HAVE YOU EVER BEN CONVICTED OF A FELONY? YES NO HAVE YOU EVER WORKED WITH ELDERLY OR DISABLED? YES NO DO YOU HAVE A VALID DRIVER'S LICENSE YES NO HAVE YOU HAD A TICKET IN THE PAST 3 YEARS? YES NO IF SO, EXPLAIN VIOLATION DO YOU HAVE RELIABLE TRANSPORTATION? YES NO Education NAME OF HIGH SCHOOL HIGHEST SCHOOL GRADE COMPLETED 9 10 11 12 COLLEGE OR TRAINING SCHOOL AND MAJOR LICENSE/CERTIFICATION NUMBER JOB EXPERIENCE MOST RECENT JOB COMPANY YEARS WORKED 1 2 3 4 5 6 7 8 9 10+ Address Address 1 Address 2 City State/Province Zip/Postal Code Country SUPERVISOR PHONE (###) ### #### DUTIES PREVIOUS JOB COMPANY YEARS WORKED 1 2 3 4 5 6 7 8 9 10+ Address Address 1 Address 2 City State/Province Zip/Postal Code Country SUPERVISOR PHONE (###) ### #### DUTIES PERSONAL REFERENCES REFERENCE 1 NAME YEARS KNOWN 1 2 3 4 5 6 7 8 9 10+ Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### OCCUPATION REFERENCE 2 NAME YEARS KNOWN 1 2 3 4 5 6 7 8 9 10+ Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### OCCUPATION I hereby authorize Achieving Smiles Waiver Services Inc to thoroughly investigate my background, references, employment record, and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations contacted by ASWS to provident relevant information regarding my current and/or previous employment and I release all persons, schools, employers of any and all claims for providing such information. I understand that misrepresentation or omission of facts may result in rejection of this application, or if hired discipline up to and including dismissal. I understand that I may be required to sign a confidentiality and/or non-complete agreement, should I become an employee of Achieving Smiles Waiver Services. I understand that nothing contained in this application, or conveyed during any interview which may be granted, is intended to create an employment contract. I understand that filling out this form does not indicate there is a position open and does not obligate Achieving Smiles Waiver Services to hire me.I understand and agree that my employment is at will, which means that it is for no specific period and may be terminated by me or Achieving Smiles Waiver Services at any time without prior notices for any reason. DATE and Signature Thank you! JOB APPLICATION
