Application for Employment
All employment decisions at Cumberland River Homes are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history, family or parental status, or any other status protected by the laws or regulations in Kentucky. Cumberland River Homes will not tolerate discrimination or harassment based on any of these characteristics.
Personal Information
Full Name
Date
Address
Apt/Suite
City
State
Zip
Email
Home Phone
Cell Phone
Social Security No.
Date Available
Desired Pay
Are you available to work any shift?
Yes
No
What shifts are you unable to work?
Are you available to work overtime?
Yes
No
Position applied for
Employment Desired
Full time
Part time
Employment Eligibility
Are you legally eligible to work in the U.S.?
Yes
No
Have you ever worked for Cumberland River Homes?
Yes
No
Start Date
End Date
Have you ever been convicted of a felony?
Yes
No
Please explain
Are you 18 years of age or older?
Yes
No
Do you have a valid driver’s license
Yes
No
Have you been convicted of a DUI in the past year?
Yes
No
Education
High School Name
City
State
From
To
Did you graduate?
Yes
No
Diploma?
Yes
No
College Name
City
State
From
To
Did you graduate?
Yes
No
Degree
Other Name
City
State
From
To
Degree/Certification
Previous Employment
Employer 1 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 2 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 3 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 4 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 5 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 6 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 7 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
Would you like to enter another employer?
Yes
No
Employer 8 Name
Phone
Address
City
State
Zip
Starting Pay
Per hour
Salary
Ending Pay
Per hour
Salary
Job Title
Supervisor Name
Responsibilities
From
To
Reason for leaving
May we contact this employer for a reference?
Yes
No
References (professional only)
Full Name
Relationship
Company
Title
Email
Phone
Add another?
Full Name
Relationship
Company
Title
Email
Phone
Add another?
Full Name
Relationship
Company
Title
Email
Phone
Military Service
Are you a veteran?
Yes
No
Branch
Rank at Discharge
From
To
Type of Discharge
If not honorable please explain
Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Signer Name
Disclaimer
I, the Applicant, certify that my answers are true and honest to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me. Additionally, If this application leads to my eventual employment, I understand that any false or misleading information in my application or Interview may result In my employment being terminated.
I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to Cumberland River Homes.
I authorize Cumberland River Homes to request and receive such information. In consideration for my employment and my being considered for employment with Cumberland River Homes, I agree to adhere to the policies, rules, and regulations of Cumberland River Homes and hereby acknowledge that these policies, rules, and regulations may be changed by Cumberland River Homes at any time, at Cumberland River Homes sole discretion and without any prior notice.
I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of Cumberland River Homes or myself.