ABUNDANT LIFE HCS CO CONTRACTOR APPLICATION

APPLICANT INFORMATION

Last Name*

First Name*

Middle Initial

Street Address*

Apt-Unit

City*

State*

Zip*

Date Available*

SSN*

DL or ID #:*

Are you authorized to work in the U.S.?*

Yes

Have you ever worked for this company?*

Yes

If so When:

Have you been convicted of, or have you pleaded guilty or no contest to, a felony offense?*

Yes

If yes, explain briefly

Emergency Contact Name

Emergency Contact Phone

Relationship

Did you graduate High School, get a GED or have a degree from an accredited college?*

Yes

FOSTER CARE APPLICANTS ONLY: Is there anyone in the household, other than yourself over the age of 18?*

Yes

DISCLAIMER AND SIGNATURE. DO NOT SIGN BEFORE READING CAREFULLY “I certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong or incomplete information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for my immediate dismissal. I understand that all such information is subject to verification by Abundant Life HCS, and hereby give my consent to Abundant Life HCS to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I agree to undergo any type of drug and/or alcohol testing that may be required at any time. Finally, I understand that submission of this application does not necessarily mean that I will be hired, and that if I am hired, my employment will be at will, and either I or Abundant Life HCS may terminate my employment at any time, with or without notice or reason."

Signature*

Date*

REQUIRED DOCUMENTATION FOR FOSTER CARE ONLY

copy of mortgage or lease showing address and contractor’s name
utility bill with contractor’s name and address (must match mortgage/lease address and name)
signed background check permission slip (applicant and anyone over the 18 living in the household)

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CHARACTER REFERENCES

Please provide 3 references. Do not include relatives.

Reference 1

First and Last Name*

Years/Months Known*

Phone Number*

Reference 1

First and Last Name*

Years/Months Known

Phone Number*

Reference 1

First and Last Name*

Years/Months Known*

Phone Number*

Signature