Kirkhaven Application Seniors First

Highschool*
Did you graduate?
- Yes
- No
Other highest grade completed
College and Course of Study*
Did You Graduate?
- Yes
- No
Other years completed
Additional Education?
Professional Licenses, Certifications, and Registrations? Provide State, ID number, and Expiration Dates:

Work Experience*
- I have no work experience.
- I have work experience. (Please list your last 3 employers, with the most recent first.)
Most Recent Employer
Employer's Address
Supervisor's Name
Phone
Your Position/Title
Hours & shift
Rate of pay
Dates employed?
Reason for leaving
Name of Employer
Employers Address
Supervisor's Name
Phone
Your Position/Title
Hours & shift
Rate of pay
Dates employed?
Reason for leaving
Name of Employer
Employer 's Address
Supervisor's Name
Phone
Your Position/Title
Hours & shift
Rate of pay
Dates employed?
Reason for leaving
Have you served in the US Armed Forces?
- No
- Yes
If Yes, please list branch of service, dates of service (from month/year - to month/year), and rank attained.

Personal References & Records Check Consent.
Please provide three (3) Personal References:
Records Check Consent.
Have you ever been convicted of a crime?*
- No
- Yes
If yes, please describe in full:
If yes, do you possess a certificate of relief from disabilities or a certificate of good conduct from the court?
- Yes
- No
I understand that a record containing convictions will not necessarily disqualify me from employment with Seniorsfirst, and that consideration will be given to the information provided including: the age of the conviction; age when the crime was committed; the seriousness of the offense;, the relationship of the offense and the job sought;demonstration of rehabilitation; and whether a certificate of relief from civil disabilities has been obtained. I understand that failure to provide Seniorsfirst with full and accurate information regarding any and all names used by me and any and all addresses at which I have resided will disqualify me from consideration for employment and will constitute grounds for discharge from employment. *
- I agree