Milemarkers – Application for Employment

Completion of this form in no way constitutes an offer of employment. The information requested is required to provide us with information necessary to consider you for any current or future job openings for which you may qualify.

Full Name


Full Address



Phone Number

Email Address

Have you ever been convicted of a: FelonyMisdemeanor Involving Moral Turpitude
If yes to either question, explain the nature of the offense, including date and location. Convictions are evaluated in relation to the applied for position. Explain:

Are you a US Citizen? YesNo
If No, are you eligible to be employed under a visa or entry permit? YesNo

Are you proficient in the following skills in the English Language? SpeakReadWrite

Are you proficient in the following skills in the Spanish Language? SpeakReadWrite

Do you have a valid Arizona Driver's License? YesNo
If yes, provide license number and class:

Education & Training

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2.)





3.)





Please list all job related licenses, registrations, certifications, with their numbers and expiration dates. Provide additional information that would be of assistance in considering you for this position (examples: CPR, First Aide, Notary, ect.)

Employment History
List all employees from the last three years, starting with the most recent first. Account for all time, employed and unemployed.

1.)

Employer



Salary/Hourly Rate




Misc.




2.)

Employer



Salary/Hourly Rate




Misc.




3.)

Employer



Salary/Hourly Rate




Misc.




4.)

Employer



Salary/Hourly Rate




Misc.




How did you learn about this position?

If you chose Social Media, Online, Community Event, Current Milemarkers Employee, or Other please provide more details:

Certificate of Applicant
I, herby, certify that the facts contained in this application are true, accurate and complete. I understand that any omissions or falsified statements on this application may be cause for disqualification for employment with Milemarkers Therapy or my dismissal. I, herby, authorize Milemarkers Therapy to verify the accuracy of all statements contained in this application, resume, and any references and employers listed. I also authorize the employers/references listed to provide Milemarkers Therapy with all information concerning my previous employment and any pertinent information they may have. I release all parties from all liability for any damages that may result from furnishing such information.

"I further understand that, if employed in a grant funded position, my continued employment is contingent upon availability of funds and any position will be abolished when the grant expires unless alternate funding is secured."

Check this box to electronically sign your application.
Name: Date: