* = Required Information
Full Time Part Time
Yes No
Yes No
Yes No N/A
Work History
LIST THE NAMES OF ALL EMPLOYERS, GIVING THE MOST RECENT POSITION FIRST. PLEASE GIVE THE MONTH AND YEAR FOR EACH POSITION LISTED. IN ADDITION, BE SURE TO LIST ALL HEALTH OR HUMAN SERVICE PROVIDERS FOR WHICH YOU HAVE WORKED. IF YOU NEED ADDITIONAL SPACE, PLEASE CONTINUE ON ANOTHER SHEET OF PAPER.


Yes No
Yes No
(INFORMATION REGARDING CONVICTIONS WILL NOT NECESSARILY DISQUALIFY YOU FOR EMPLOYMENT, BUT WILL BE REVIEWED IN LIGHT OF THE DUTIES AND RESPONSIBILITIES OF THE POSITION BEING SOUGHT) DRIVER’S LICENSE NUMBER & STATE* CURRENTLY VALID? Yes No *A VALID DRIVER’S LICENSE AND ACCEPTABLE DRIVING RECORD ARE REQUIRED FOR MANY POSITIONS
Education
1 2 3 4
Yes No
1 2 3 4
Yes No
1 2 3 4
Yes No
Professional licenses and/or certifications
Yes No
Military Experience
Yes No
Related Information
References
Yes No
Yes No
Give three work-related references


Authorization and release of information
I hereby give RiteChoice Family Services, hereafter known as RFS, the right to thoroughly investigate my past employment, education, police record, activities, and I release from all liability all persons, companies, and corporations supplying such information. I indemnify RFS against any liability which might result from conducting such an investigation.

I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between RFS and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon RFS unless made in writing by the President. If any employment relationship is established, I understand that I have the right to terminate my employment at any time for any reason or no reason at all, with or without prior notice, and that RFS retains the same right.