Position applied for

1. First Name: Last Name: M.I

Your name if different from present:

2. SSN: / /  3. D.OB:

4. Address:

5. Home Phone:  6.Cell Phone/Pager:

7. Education:

a. Circle highest grade completed 1 2 3 4 5 6 7 8 9 10 11 12 and Year Completed

b. If you did not complete high school, do you have equivalency diploma?  YesNo

c. Date Received

d. Circle number of years of post high school education 1 2 3 4 5 6 7

9. EXPERIENCE: Use Supplementary Experience Form(s) for additional space. Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position. You may list significantly different jobs within the same organization as separate items. May we contact your present supervisor?  YesNo

a. Job Title:  Duties:

Employer: Phone: Type of business:

Address:

Immediate supervisor: Salary (start): (finish):

Date Start: / to: /  Reason for leaving:

Full Time: Part Time: Hours/week:

b. Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, special achievements or specialized skills:

c. License (to include driver's), certificate or other authorization to practice a trade or profession.

10. REFERENCES List names, addresses and relationships of three persons not related to you who know your qualifications:

11. MISCELLANEOUS

a. Check which shift you will accept: Day Evening Night Rotating

Weekends Specify shift hours

b. Check, which job status you will accept: Full-time: Part-time (specify):

c. For purpose of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?  YesNo Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be employed.

d. Are you willing to provide your own transportation if necessary for your employment?  YesNo

e. Have you ever been convicted* for any violation(s) of law?  YesNo If YES, please provide the following: Description of offense:

Statute or ordinance (if known): Date of Charge:

Date of Conviction County, City and State of Conviction:

(For additional convictions use plain paper. Include all information listed above.)
*Convictions include Virginia juvenile adjunctions for Capital Murder, First and Second Degree Murder, Lynching or Aggravated Malicious Wounding, if you were age of fourteen (14) to (18) when charged.

13. CERTIFICATION: Each Application Requires Current Date and Original Signature I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the FAMA Healthcare Services LLC. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further authorize the FAMA Healthcare Services LLC to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need to- know basis for good cause shown as determined by the agency head or designee.

Date:  Applicant Signature: