* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time Seasonal

* Hourly rate/salary desired:

* Are you currently employed?:

Yes   No

If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
	Yes   No
	Yes   No
	Yes   No

Give your full employment record, starting with your current or most recent employment

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Employment Type
		Type Full timePart timeSeasonal

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Employment Type
		Type Full timePart timeSeasonal

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Employment Type
		Type Full timePart timeSeasonal

Name	Relationship	Phone Number	Email

I hereby certify that all of the foregoing information I have supplied in the application for employment is true and correct. I also understand that Family Care Network, Inc. (FCNI) will verify the information and in the event that it is discovered that any of the information is false, I will be terminated immediately upon discovery. I give Family Care Network, Inc. permission to contact any and all of my previous employers, educational institutions and references for full information and hereby release Family Care Network, Inc. and my previous employers, educational institutions and references from any liability for doing so.

If selected by Family Care Network, Inc. for the position for which I have applied, I understand that as a condition of employment, the following will be required:

• I will be drug tested at FCNI's expense and authorize FCNI to receive the test results.
• I will be examined by a physician at FCNI's expense to determine if I am physically able to perform the duties of the job.
• I will complete and submit a State of California Criminal Record Statement. If I have been convicted of a crime, I will provide all necessary documentation to be used to determine if I am employable by this facility.
• I will be fingerprinted at FCNI's expense and my fingerprints will be sent to the Department of Justice for clearance. The level of clearance required will depend on the position for which I am applying.

If employed, I agree to conform to the rules, procedures and policies of Family Care Network. Inc. I understand that if hired, I may be transferred, reassigned, suspended, demoted or terminated from employment at any time, with or without notice or cause. I further understand that no employee or agent of Family Care Network, Inc. has any authority to enter into any agreement of employment which is contrary to the foregoing.

* Signature (type name):

* Date: