REGENCY MANAGEMENT GROUP, LLC

APPLICATION FOR EMPLOYMENT

PLEASE PRINT

Position(s) applied for: ______________________ Date of Application: ______________

Referral Source: [  ] Advertisement
[  ] Employment Agency
[  ] Employee		 Newspaper:
Name:
[  ] Relative		 ________________________
________________________
[  ] Friend              [  ] Walk-in

Name: _____________________________________________________________________
                Last                                                        First                                                          Middle


Address: ___________________________________________________________________
                 Street                                                     City                                            State          Zip


Telephone Number: ____________________ Social Security Number: ____/_____/____


If necessary, best time to call you at home is: __________am / pm


May we contact you at work? [  ] Yes    [  ] No
   If Yes, work number and best time to call:  ____________________________ am / pm


If you are under 18, are you a student?  [  ] Yes   [  ] No
  (If Yes, please provide details on page 3)


If you are under 18, can you furnish a work permit?  [  ] Yes     [  ] No


Have you filed an application before?  [  ] Yes     [  ] No
    If Yes, give date:  _____/_____/_____ 


Have you ever been employed here before?    [  ] Yes     [  ] No
     If Yes, give dates:  From:  _____/_____/_____   To:  _____/_____/_____ 

Date available for work:  _____/_____/_____ 

Type of employment desired:  [  ] Full-time     [  ] Part-time     [  ] Educational Co-op


Are you on a lay-off and subject to recall?    [  ] Yes     [  ] No


Will you relocate if required?    [  ] Yes     [  ] No     Will you travel if required?    [  ] Yes     [  ] No


Are you able to meet the attendance requirements of the position?   [  ] Yes     [  ] No
(This may include evening and week-end meetings - see job description for details)

Will you work overtime if required?    [  ] Yes     [  ] No

Skills and Qualifications: Summarize any special training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position for which you are applying:

___________________________________________________________________________

 ___________________________________________________________________________

 ___________________________________________________________________________

 

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in "Comments" section below.
Employer                        Telephone

                                       (    )                      		 Dates Employed

From

To

 Summarize the nature of the work performed and job responsibilities:
Address
   
   
Job Title

Hourly Rate/Salary
(Starting)

  
Immediate Supervisor and Title
$ Per
  
Reason for Leaving Hourly 
Rate/Salary
(Final)		  
May we contact for a reference? [  ] Yes [  ] No
$ Per
  
Employer                        Telephone

                                       (    )                      		 Dates Employed

From

To

 Summarize the nature of the work performed and job responsibilities:
Address
   
   
Job Title

Hourly Rate/Salary
(Starting)

  
Immediate Supervisor and Title
$ Per
  
Reason for Leaving Hourly 
Rate/Salary
(Final)		  
May we contact for a reference? [  ] Yes [  ] No
$ Per
  
Employer                        Telephone

                                       (    )                      		 Dates Employed

From

To

 Summarize the nature of the work performed and job responsibilities:
Address
   
   
Job Title

Hourly
Rate/Salary
(Starting)

  
Immediate Supervisor and Title
$ Per
  
Reason for Leaving

Hourly 
Rate/Salary
(Final)

  
May we contact for a reference? [  ] Yes [  ] No
$ Per
  
Employer                        Telephone

                                       (    )                      		 Dates Employed

From

To

 Summarize the nature of the work performed and job responsibilities:
Address
   
   
Job Title

Hourly
Rate/Salary
(Starting)

  
Immediate Supervisor and Title
$ Per
  
Reason for Leaving

Hourly 
Rate/Salary
(Final)

  
May we contact for a reference? [  ] Yes [  ] No
$ Per
  

Comments (including explanation of any gaps in employment) _____________________________

______________________________________________________________________


A. List last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank, and E. Major and minor fields of study (if applicable).

A. School

B. Years
Completed

C. Degree/
Diploma

D. GPA/
Class Rank

E. Major

E. Minor

           
           
           


List any foreign language(s) you know and check the boxes indicating your skill level.

Language

Speak Some

Speak Fluently

Read

Write

         
         
         
         


REFERENCES

List name and telephone number of three personal references who are not related to you and are not previous supervisors.

Name

Telephone

Years Known

  (     )       -  
  (     )       -  
  (     )       -  
List professional, trade, business, or civic association and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)

Organization

Offices Held

    
   
   
List special accomplishments, publications, awards (exclude information which would reveal sex, race, religion, national origin, age, color, disability, or other protected status):

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

List any additional information you would like us to consider: _____________________________________

________________________________________________________________________________________

____________________________________________________________________

It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's services, if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job-related. I give the employer the right to perform a background check and credit reference check, if necessary. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment, and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause, and without prior notice (except as otherwise noted in an employment agreement, if executed.) I understand that no representative of the employer has the authority to make any assurances to the contrary.

I understand it is this company's policy not to refuse to hire a qualified individual with a disability because of this person's need for an accommodation that would be required by the ADA.




Signed: ________________________________ Date: _______________________________