Employment Application – Sunflower Adult Day Services

Position you are applying for

Applicant Name

First

Last

SS# (last 4 of SS) - Full SS will need to be disclosed at a further date.

List any relatives or friends currently employed by Sunflower Adult Day Services:

Email (optional)

Phone #

School Type

Degree (select from dropdown)

School Type

Degree (select from dropdown)

School Type

Degree (select from dropdown)

Most Recent/Current Employer

Address

City State Zip

Phone #

Position/Work Performed

Reason for Leaving

From Date

To Date

Supervisor

Salary

Employer #2

Address

City State Zip

Phone #

Position/Work Performed

Reason for Leaving

From Date

To Date

Supervisor

Salary

Employer #3

Address

City State Zip

Phone

Position/Work Performed

Reason for Leaving

From Date

To Date

Supervisor

To do #'s

Salary

Additional Comments or information you would like to share with us.

Please list three people who can speak to your character and work ethic. References should not be relatives and should preferably be former employers, teachers, or co-workers rather than personal friends. By completing this form, you authorize us to contact the individuals listed.

First Reference Name:

Address/City/State:

Phone #'s

How do you know this person:

Second Reference Name:

Address/City/State:

Phone #'s

How do you know this person:

Third Reference Name:

Address/City/State:

Phone #'s

How do you know this person:

Signature

Date