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Job Application

EMPLOYMENT APPLICATION

Please complete the entire application.
Employer: POW, LLC
Address: 460 E. Carson Plaza Drive, Suite 206C
City/State/ZIP: Carson, California 90746

POW, LLC offers an equal opportunity for employment, and a competitive rate of pay to all applicants without regard to race, ethnicity, age, sex, gender identity, color, marital status, sexual orientation, religion, gender, national origin, disability, or veteran status. Should you require reasonable accommodation to complete this application, please inform us so that a reasonable accommodation can be made.

We are committed to providing quality and ethical care to our patients, residents, and consumers. We are also committed to providing a safe environment for our patients, residents, consumers, and employees. Therefor; it is also the policy of our company to conduct a pre-employment drug screen. Once a conditional offer of employment has been made, we will run a background check on all employees. If your position requires that you drive a vehicle, we will also obtain a DMV clearance. Failing the background check shall be just cause to terminate your employment. If you fail the DMV clearance, and your position requires you to drive a vehicle, you may be terminated or experience a change in employment status.

"*" indicates required fields

Step 1 of 6

16%

Applicant Information

Last Name*

First Name*

Middle Name*

Home Address*

City/State/ZIP*

Number of years at this address

Daytime Phone

Evening Phone

Mobile phone*

Email*

Driver's License (State/Number)

Position Applied for

Are You Applying for

Full Time

Part Time

How Did You Learn About This Position?

Do You Have Any Friends or Relatives Who Work Here? If Yes, Please List Here:

Are You at Least 18 Years Old?

Yes

Are You Willing to Work Any Shift, Including Nights and Weekends?

Yes

If No, Please State Shift of Preference and Any Other Limitations

If Applicable, Are You Available to Work Overtime?

Yes

If You Are Offered Employment, When Would You Be Available to Begin Work?

If Hired, Are You Able to Submit Proof That You Are Legally Eligible for Employment in the United States?

Yes

Are You Able to Perform the Essential Functions of This Position With or Without Reasonable Accommodation?

Yes

What Reasonable Accommodation, if Any, Would You Request?

Skills, Knowledge and Abilities

List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Ability or Skill

Years of Experience

Rating

Ability or Skill

Years of Experience

Rating

Ability or Skill

Years of Experience

Rating

Ability or Skill

Years of Experience

Rating

Ability or Skill

Years of Experience

Rating

Employment History

List your current or most recent employment first. Please list all jobs for the past 10-years (including school, self-employment, and military service) which you have held, please list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

Employer Name

Phone

Supervisor Name

City/State/ZIP

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

DD slash MM slash YYYY

May We Contact This Employer?

Yes

Employer Name

Phone

Supervisor Name

City/State/ZIP

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

DD slash MM slash YYYY

May We Contact This Employer?

Yes

Employer Name

Phone

Supervisor Name

City/State/ZIP

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

DD slash MM slash YYYY

May We Contact This Employer?

Yes

Education and Training

Name of High School or Place Where Hs Diploma or GED received

College/University (s) Name and Address

Did You Receive a Degree?

Yes

If yes, Degree received

Other Training (Graduate, Technical, Vocational)

Please Indicate Any Current Professional Licenses or Certifications That You Hold:

Type of License or Certificate

License or Certificate Number

Expiration Date

MM slash DD slash YYYY

Military Service

Yes

Branch

Specialized Training

References

List any two non-relatives who would be willing to provide a reference for you.

Name

Address

City/State/ZIP

Telephone

Relationship

Name

Address

City/State/ZIP

Telephone

Relationship

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that omitting information, or providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Lead the Way, LLC to contact former employers, educational organizations, and non-relative references regarding my employment, character, and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my character, previous employment, and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Director, the employment relationship will be "At-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Lead the Way, LLC Home, except in a specific written contract of employment signed on behalf of the organization by its Executive Director, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Applicant Signature

Date

MM slash DD slash YYYY

If This Application Has Been Completed by Someone Other Than the Applicant, Please Print Their Name Below:

Employee Availability Form

Date

MM slash DD slash YYYY

Employee Name (Print)

Employee Signature

Date You Can Officially Start

MM slash DD slash YYYY

Will There Be Any Prior Commitment Dates That Will Affect Work

Instructions: In each blank, record the times you are available to work.

• If you can work any time, write NO RESTRICTIONS.
• If you cannot work on a given day, write NO AVAILABILITY.
• All Week shifts are 8 hour shifts. The shifts are: 8am-4pm, 4pm-12am, 12am-8am
• All Weekend shifts are 12 hour shifts. The shifts are: 8am-8pm, 8pm-8am
• Please include A.M. and P.M.

EMPLOYEE AVAILABILITY

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Note:
• You must complete this form before we can add you to the schedule.
• It is your responsibility to update this form and turn it in to your manager if your availability changes.
• We are not responsible for conflicts in scheduling that arise because you neglected to update your availability.
• Updating your availability does not guarantee it will be accommodated.

Comments

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