The Homeplace on Green River, Inc.

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Contract for Labor Application

APPLICANT INFORMATION

Last Name First M.I.______ Date

Street Address_________________________________________________________ Apt/Unit#

City State Zip Code

Home Ph Cell Ph Email Address______________

Desired
Date Available:________________ Social Security No. - - Salary

Have you been convicted of a crime other than a traffic offense? Please note: Convictions are not grounds for
automatic rejection:

Are you willing to take a drug screen for illegal use according to our policy? Yes No

EDUCATION

High School: Address:

From : To: Did you graduate? Yes No Degree:

College Address:

From : To: Did you graduate? Yes No Degree:

Other: Address:

From : To: Did you graduate? Yes No Degree:

PREVIOUS EMPLOYMENT
Most Recent Company: Phone:

Address: Supervisor

Job Title: Starting Salary ___________ Ending Salary:_______

Responsibilities:
From:_______ To:__________ Reason for leaving:

May we contact your previous supervisor for a reference? Yes No

Company: Phone:
Address: Supervisor:
Job Title: Starting Salary ___________ Ending Salary:_______
Responsibilities:

Will you release your background information inclusive of criminal records? Yes No

DRUG SCREEN AUTHORIZATION AND CONSENT: I hereby authorize and give full permission to have The
Homeplace on Green River, Inc., and/or their medical clinic of their choosing to send a specimen of my urine and/or
blood and/or hair follicles to a laboratory for screening test using S.A.M.H.S.A. standards for the presence of illegal
drugs.

I will hold all parties concerned harmless, meaning I will not sue nor hold responsible for any alleged harm to me or
interfering with my obtaining a job or continuing employment due to not submitting to the tests or as a result of the
test. This includes, but is not limited to, possible clerical or laboratory error.

This policy and authorization has been explained to me in language I understand and I have been told that if I have
any questions about the test they will be answered. I understand this is a legal binding document which is binding
because The Homeplace on Green River, Inc., is sending me for the examination and paying for it.

I UNDERSTAND THE HOMEPLACE ON GREEN RIVER, INC., WILL REQUIRE A DRUG SCREEN
TEST WHENEVER AN ON-THE-JOB ACCIDENT OF INJURY IS REPORTED IN ACCORDANCE
WITH COMPANY POLICY. MY REFUSAL TO SUBMIT TO DRUG TESTING WILL BE GROUNDS
FOR TERMINATION.
Initials
REFERENCES
Please list three professional references:
1. Full Name Relationship:
Company: Phone:
Address:

2. Full Name Relationship:

Company: Phone:
Address:

3. Full Name Relationship:

Company: Phone:
Address:

PLEASE READ: I authorize you to check my references regarding past employment.

@ Date

MILITARY SERVICE
Branch: From: To:
Rank of Discharge: Type of Discharge:
If other than honorable, please explain:

DISCLAIMER AND SIGNATURE

I hereby declare that all statements contained in this application are true and correct and understand that false or inaccurate
information in the application will be the basis for termination. I hereby authorize The Homeplace on Green River
Inc., to investigate my background inclusive of criminal records and verify this information. I understand that if
employed, my employment is at will and not for any fixed period of time and may be terminated by The Homeplace
on Green River, Inc., or me at any time. I also authorize The Homeplace on Green River, Inc., to release information
contained herein and its findings and work history of my employment to other employers or persons upon
request. I also agree to submit to a drug screen upon request or as specified by policy

Applicant Printed Name and Signature Date