JOB APPLICATION

Rapha Companion Services
, ,

561-331-5931

Raph Companion Services is an equal-opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need a reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information

Applicant Name:*

Address:*

City, State and Zip Code:*

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

Telephone Number:*

Email Address:*

Date of Application:*

Employment Position

Position(s) applying for: Contractor application

How did you hear about this position?*

What days are you available for work?*

What hours or shift are you available for work?*

If needed, are you available to work overtime?*

On what date can you start working if you are hired?*

Do you have reliable transportation to and from work?*

Salary desired:*

Personal Information

Have you ever applied to or worked for Rapha Companion Services before?

Yes
No
If yes, when?

*

Do you have any friends, relatives, or acquaintances working for Rapha Companion Services

Yes
No
If yes, state name & relationship:

*

Are you 18 years of age or older?

Yes
No

*

Are you a U.S. citizen or approved to work in the United States?

Yes
No

*

What document can you provide as proof of citizenship or legal status?*

Will you consent to a mandatory controlled substance test?

Yes
No

*

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes
No

*

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:*

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:*

(Note: Rapha Companion Services complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )

Education and Training

High School

Name*

First

Location (City, State)*

Year Graduated*

Degree Earned*

College/University

Name*

Location (City, State)*

Year Graduated*

Degree Earned*

Vocational School/Specialized Training

Name*

Location (City, State)*

Year Graduated*

Degree Earned*

Military:

Are you a member of the Armed Services?*

What branch of the military did you enlist?*

What was your military rank when discharged?*

How many years did you serve in the military?*

What military skills do you possess that would be an asset for this position?*

Previous Employment

Employer Name:

Job Title:*

Supervisor Name:*

Employer Address:*

City, State and Zip Code:*

Employer Telephone:*

Dates Employed:*

Reason for leaving:*

Employer Name:

Job Title:*

Supervisor Name:*

Employer Address:*

City, State and Zip Code:*

Employer Telephone:*

Dates Employed:*

Reason for leaving:*

Employer Name:

Job Title:*

Supervisor Name:*

Employer Address:*

City, State and Zip Code:*

Employer Telephone:*

Dates Employed:*

Reason for leaving:*

Additional Information:

Do you have a valid driver license*

Are able to do a level 2 screening (background check)*

SS#*

Do you have Authorization to work work in the USA*

AT-WILL EMPLOYMENT

The relationship between you and Rapha Companion Services is called "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or Rapha Companion Services. No representative of Rapha Companion Services has the authority to enter into any agreement contrary to the preceding "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature:*

Date*

JOB APPLICATION

Rapha Companion Services , ,

Applicant Information

Employment Position

Personal Information

Job Skills/Qualifications

Education and Training

High School

College/University

Vocational School/Specialized Training

Military:

Previous Employment

Employer Name:

Employer Name:

Employer Name:

Additional Information:

AT-WILL EMPLOYMENT

Rapha Companion Services
, ,