Continuous Care Services -- Resume Submission

Application for Employment

An Equal Opportunity Employer

We are an equal opportunity employer, and we do not and will not discriminate on the basis of race, religion, national origin, sex, age, handicap, marital status, or status as a disabled veteran. Information provided on this application will not be used for any discriminatory purpose.

Social Security Number
Email Address
Last Name
First Name
Middle Initial
Street Address
City
State
Zip
Home telephone
Work telephone
Type(s) of work desired

How were you referred to us
By your College
Advertisement
Employment Agency
By an Employee		If so what was the name
Open House
Walk-in
Other

Employment Record

Starting with present or most recent, list all previous employers. Include self-employment and summer and part-time jobs. If more space is required, please continue on a separate sheet. You may attach a resume, but complete this application as well.

Last or present Company	Type of Business
Street Address	City
State	Zip
Supervisors name	Phone number
Base salary	Dates worked	From
		To
Reason for leaving
Type of classification of job
Brief description of job duties

Last or present Company	Type of Business
Street Address	City
State	Zip
Supervisors name	Phone number
Base salary	Dates worked	From
		To
Reason for leaving
Type of classification of job
Brief description of job duties

Last or present Company	Type of Business
Street Address	City
State	Zip
Supervisors name	Phone number
Base salary	Dates worked	From
		To
Reason for leaving
Type of classification of job
Brief description of job duties

Educational History

School name	Location (city, state)	Major course or subject	Dates Attended		Graduated		Degree
School name	Location (city, state)	Major course or subject	From	To	Yes	No	Degree
High School

Technical trade (after high school)

College (list all attended)


Other education training

Outside Activities

(Exclude those indicating race, color, religion, sex, national origin, age, or handicap)

Professional memberships, certificates, or licenses held

Past and present civic or cultural activities -- include office held

Principal hobbies

Special Skills

To be completed for a office/clerical worker			To be completed by applicant for shop/plant work
Typing	Yes	Words per minute:	Types of machined operated		Years experience
	No
Dictation	Yes	Words per minute:
	No
Computer Skills	Hardware
	Software
Please list other skills and/or equipment/language experience you have acquired			List other shop/production skills

			Served apprenticeship	Yes	Type:
				No

Military Record

Branch of service	From	To
Present militiary affiliation	None	Reserve (active)	Reserve (inactive)
Kinds of training while in service

Professional/Work References

List two past supervisors and one person who are not related to you who have knowledge of your qualifications for the position for which you are applying.

Name:
Title/Relationship:
City, State
Phone:
EMail:
Occupation

Name:
Title/Relationship:
City, State
Phone:
EMail:
Occupation

Name:
Title/Relationship:
City, State
Phone:
EMail:
Occupation

May we contact your present employeer Yes No

Wage or salary required
Date available

I hereby certify that the answer and other information on this application are true and correct and that I understand any misrepresentation or omission of facts on my part will be justification for separation from the company’s service, if employed. I understand that my employment may be contingent upon receipt of an alien registration number, verification of birth, and any other pertinent information bearing upon my employment, and that my continued employment depends upon the will of the company or myself.

Agree	Disagree

Continuous Care Services

Tennessee
Nashville
545 Mainstream Drive, Suite 100
Nashville, TN 37228
Corporate Office (615) 263-4425
Murfreesboro Office:
615-896-4482
Alabama

Birmingham Office:
484 Palisades Blvd
Birmingham, AL 35209
205-802-7172
800-588-1593 (toll free in-state only)
205-802-7153 (fax)
Tuscaloosa Office:
513 Energy Center Blvd Suite 1004
Northport, AL 35476
205-345-9892
800-647-8503 (toll free in-state only)
205-345-9356 (fax)





Continuous Care Services

Tennessee Nashville 545 Mainstream Drive, Suite 100 Nashville, TN 37228 Corporate Office (615) 263-4425 Murfreesboro Office: 615-896-4482	Alabama Birmingham Office: 484 Palisades Blvd Birmingham, AL 35209 205-802-7172 800-588-1593 (toll free in-state only) 205-802-7153 (fax) Tuscaloosa Office: 513 Energy Center Blvd Suite 1004 Northport, AL 35476 205-345-9892 800-647-8503 (toll free in-state only) 205-345-9356 (fax)