Employment Application Form

Applicant name LaQueendra Jackson Current Address 2 Farmer Street Cahaba Park West Home Phone N/A Number and Street 2 Farmer Street Other (334)553-1108 City, State,& Zip Selma, AL 36701 Email Address LaQueendraJ@gmail.com

How were you referred to company?: By Dallas County High School__________________

Employment Positions
Position(s) applying for: Assistant nurse/ licensed Vocational Nurse_______________

Are you applying for:

Temporary work such as summer or holiday work? Regular part-time work? N Regular full-time work? N [ ]Y [ ]Y [ ]Y [X] N [X] [X]

What days and hours are you available for work? Monday-Friday 9 a.m. 10p.m __________ If applying for temporary work, when will you be available? Monday Thursday ______________ If hired, on what date can you start working? 11/10/13 Can you work weekends? N Can you work evenings? N [X] Y [Y] Y [ ] [ ]

Are you available to work overtime? N Salary desired: $ 9.00 per hour_____________

[X] Y

[ ]

Personal Information:
Have you ever applied to/ worked for company before? N If yes, please explain (include date): _________________________________________________ Do you have any friends, relatives, or acquaintances working for company? N If yes, state name & relationship: ________________________________________ If hired, would you have transportation to/from work? N [X] Y [ ] [ ]Y [X] [ ]Y [X]

Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.) [ ] Y [X] N If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? [X] Y [ ] N If hired, are you willing to submit to and pass a controlled substance test? [X] Y [ ] N

Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation? [X] Y [ ] N If no, describe the functions that cannot be performed _________________________________ Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ ] Y [X] N

If yes, please describe the crime- state nature of the crime(s), when and where convicted and disposition of the case.___________________________________________________________

Education, Training and Experience High School

School name School address School City, State, Zip: Number or years completed Degree / Diploma Earned

Southside High School Dallas County Schools

7975 U.S. Highway 80 East 335 Fifth Avenue

Selma, AL 367011003 Plantersville, AL 36758

One school year

N/A

Half school year

N/A

Did you graduate? N

[ ] Y [X]

Related details: Assistant nurse at Nanas Day Care Center____________________________ Do you speak, write or understand any foreign languages? N [ ] Y [X]

If yes, describe which language(s) and how fluent of a speaker you consider yourself to be. ______________________________________________________________________________ Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us? [X] Y [ ] N If yes, explain: I love to dance sing do art and love working with children. ______________

Employment History
Are you currently employed? If you are currently employed, may we contact your current employer? [ ] Y [X] N [ ]Y [ ]N

Below, please describe past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this

section must be completed.

Name of employer: Nana Johnson_____________________ Name of supervisor: Nana Johnson______________________ Telephone number: (334)875-1315_____________________ Business type: Day Care Center_________________________ Address: 2020 Landline Road____________________________ City, State, Zip: Selma, AL 36701______________________

Length of employment (include dates): Three years____________________ Positions & Duties: assistant nurse helps the kids with scrapes and sores.____________ Reason for leaving: ______________________________________ May we contact this employer for reference? N Name of employer: ________________________________ Name of supervisor: _______________________________ Telephone number: _______________________________ Business type: [___________________________________ Address: ________________________________________ City, State, Zip: ___________________________________ Length of employment (include dates): ___________________________________ Positions & Duties: ________________________________ Reason for leaving: ______________________________________ May we contact this employer for reference? Name of employer: ________________________________ Name of supervisor: _______________________________ Telephone number: _______________________________ Business type: [___________________________________ Address: ________________________________________ City, State, Zip: ___________________________________ Length of employment (include dates): ___________________________________ Positions & Duties: ________________________________ Reason for leaving: ______________________________________ May we contact this employer for reference? [ ]Y [ ]N [ ]Y [ ]N [X] Y [ ]

References

List below three persons who have knowledge of your work performance within the last four years. Please include professional reference only. 1. Name- First, Last: Ms.Alyce Johnson _____________ Telephone Number: (334)872-335____________ Address: 1215 J.L Chestnut____________ City, State, Zip: Selma, AL 36701 ___________ Occupation: Teacher____________ Number of Acquainted: ____________ 2. Name- First, Last: Ms. Africa Tyler_____________ Telephone Number: (334)267-8404____________ Address: 5656 Bib Street____________ City, State, Zip: Selma, AL 36701___________ Occupation: Doctor___________ Number of Acquainted: __________ 3. Name- First, Last: Mr. Evans____________ Telephone Number: (334)526-1100__________ Address: 2030 Raceway___________ City, State, Zip: Selma, AL 36701___________ Occupation: Dance Instructor_____________ Number of Acquainted: ___________________ 4. Name- First, Last: Mr. ONeal_________ Telephone Number: (334)505-3404___________ Address: 2545 Jackson Street___________ City, State, Zip: Selma, AL 36701___________ Occupation: Drivers Education__________ Number of Acquainted: ___________________

Please read and initial each paragraph, then sign below.

__X__ I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company.

__X__ I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company. __X__ I permit the company to examine my reference, record of employment, education record, and any other information I have provided. I authorized the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons, corporation, partnerships & associations from any & all claims, demands, or liabilities arising out of or in any way related to such examination or revelation.