Employment Application - Kimi Nichols Center

General Information

Full Name*

First M Last

Permanent Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Email*

Are you legally entitle to work in the U.S.?*

Yes
No

Social Security #

Position

Salary Desired

Are you able to perform the essential functions of the job you are applying for, with or without reasonable accomodation?*

Yes
No

Will Accept:

Part Time
Full Time

Shifts You Can Work:

Day
Residential
One on One Staff

Education/U.S. Military Service

High School Graduate or General Education (GED) test passed*

Yes
No

Highest Grade Completed

Where did you attend high school & college? (Click the + button to add a new row)*

School Name & Address	Major	Dates Attended	GPA	Degree/Diploma

Special Skills

List all pertinent skills

Have you ever served in the U.S. Armed Services?*

Yes
No

Dates Served

From - To

Work Experience

List most recent first.

Company Name (Most Recent)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Last Salary

Dates Employed

From	To

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Did you have another job before this one?*

Yes
No

Company Name (Second Most Recent)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Last Salary

Dates Employed

From	To

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Would you like to list another previous job?

Yes
No

Company Name (Third Most Recent)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Last Salary

Dates Employed

From	To

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Would you like to list a 4th job?

Yes
No

Company Name (Fourth Most Recent)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Last Salary

Dates Employed

From	To

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

References

List individuals who are familiar with your work (Click the + button to add a new row)

Name	Address	Phone	Relationship

I do hereby authorize the following individuals/agencies to release information related to my employment to KNC, Inc. (Kimi Nichols Center).

Employer 1

Employer 2

Employer 3

Employer 4

Digital Signature:*
Typing your First Name + Middle Initial + Last Name will act as your digital signature.

Date*
Date Format: MM slash DD slash YYYY

Miscellaneous Information

I have a car available and I am willing to utilize it in the performance of my duties.*
Yes
No

I have a current, VALID driver's license.*
Yes
No

I have automobile insurance on my vehicle, or I am willing to place insurance which meets KNC requirements (Liability insurance $100,000/$300,000 per person, per accident)*
Yes
No

I can provide documentation that I am at least eighteen (18) years of age.*
Yes
No

I am willing to work overtime, if required by my position.*
Yes
No

Based on a review of the description of the job of which you have applied, are you able to meet and/or perform the qualifications, requirements, and job specifications as defined in the job description?*
Yes
No

Have you ever pled guilty, or been found guilty of a crime, civilian or military?*
Yes
No

Please provide details.

Conditions of Hire

KNC requires a driving record check from the NH - Dept. of Safety or from state with current, valid driver's license before employment commences.
KNC requires a physical examination before employment commences.
KNC requires a Criminal Record check from the NH - Dept. of Safety after being hired.
Additionally, KNC requires that all employees undergo a blood or urine test as a condition of pre-employment screening.

I certify the information contained in this application is true, correct and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal.

Digital Signature:*
Typing your First Name + Middle Initial + Last Name will act as your digital signature.

Date*
Date Format: MM slash DD slash YYYY

Resume Upload (optional)
Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf.
If you have a resume you'd like to attach, please do so here. This is not required.

Would you like to add a cover letter?
Yes
No

Cover Letter (optional)
Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.

CAREERS

KNC Application for Employment

General Information

Position

Education/U.S. Military Service

Work Experience

References

Miscellaneous Information

Conditions of Hire