Employment Application

6813 S. College Avenue, Fort Collins, CO 80525 info@elderhaus.org 970.221.0406

DATE (MM/DD/YYYY) *

FULL NAME *

First

Middle

Last

ADDRESS (Street Address, Apt/Suite, City, State, Zip) *

EMAIL *

DATE AVAILABLE *

DESIRED PAY $ *

PAY BASIS *

Per Hour
Monthly Salary
Annual Salary

POSITION APPLIED FOR: *

EMPLOYMENT DESIRED *

FULL-TIME
PART-TIME
SEASONAL

ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.?

HAVE YOU EVER WORKED FOR ELDERHAUS? *

IF YES, WRITE THE START AND END DATES:

HAVE YOU EVER BEEN CONVICTED OF A FELONY? *

IF YES, PLEASE EXPLAIN:

HIGH SCHOOL EDUCATION - HIGH SCHOOL NAME AND CITY/STATE, DATES ATTENDED *

HIGH SCHOOL GRADUATE? *

NO
YES, NO DIPLOMA
YES, DIPLOMA

COLLEGE EDUCATION - COLLEGE NAME AND CITY/STATE, DATES ATTENDED *

COLLEGE GRADUATE? *

NO
YES, NO DIPLOMA
YES, DIPLOMA

IF COLLEGE GRADUATE, WHAT DEGREE?

OTHER EDUCATION - PLEASE EXPLAIN WITH INSTITUTION, CITY/STATE, DATES ATTENDED, GRADUATED, DEGREE/CERTIFICATION (LIST ALL ADDITIONAL EDUCATIONAL ACCOMPLISHMENTS)

PREVIOUS EMPLOYMENT - EMPLOYER 1 (Company/Individual) *

EMPLOYER 1 E-MAIL *

EMPLOYER 1 PHONE NUMBER *

EMPLOYER 1 ADDRESS (Street Address, Apt/Suite, City, State, Zip) *

EMPLOYER 1 STARTING PAY : $ *

EMP 1 STARTING PAY BASIS *

HOURLY
MONTHLY SALARY
ANNUAL SALARY

EMPLOYER 1 ENDING PAY : $ *

EMP 1 ENDING PAY BASIS *

HOURLY
MONTHLY SALARY
ANNUAL SALARY

EMPLOYER 1 JOB TITLE *

EMPLOYER 1 JOB RESPONSIBILITIES *

EMPLOYER 1 DATES OF SERVICE (FROM -TO) *

EMPLOYER 1 REASON FOR LEAVING *

PREVIOUS EMPLOYMENT - EMPLOYER 2 (Company/Individual)

EMPLOYER 2 E-MAIL

EMPLOYER 2 PHONE

EMPLOYER 2 ADDRESS (Street Address, Apt/Suite, City, State, Zip)

EMPLOYER 2 STARTING PAY $

EMP 2 STARTING PAY BASIS

HOURLY
MONTHLY SALARY
ANNUAL SALARY

EMPLOYER 2 ENDING PAY $

EMP 2 ENDING PAY BASIS

HOURLY
MONTHLY SALARY
ANNUAL SALARY

EMPLOYER 2 JOB TITLE

EMPLOYER 2 RESPONSIBILITIES

EMPLOYER 2 DATES OF SERVICE (FROM-TO)

EMPLOYER 2 REASON FOR LEAVING

PREVIOUS EMPLOYMENT - EMPLOYER 3 (Company/Individual)

EMPLOYER 3 E-MAIL

EMPLOYER 3 PHONE

EMPLOYER 3 ADDRESS (Street Address, Apt/Suite, City, State, Zip)

EMPLOYER 3 STARTING PAY $

EMP 3 STARTING PAY BASIS

HOURLY
MONTHLY SALARY
ANNUAL SALARY

EMPLOYER 3 ENDING PAY $

EMP 3 ENDING PAY BASIS

HOURLY
MONTHLY SALARY
ANNUAL SALARY

EMPLOYER 3 JOB TITLE

EMPLOYER 3 RESPONSIBILITIES

EMPLOYER 3 DATES OF SERVICE (FROM-TO)

EMPLOYER 3 REASON FOR LEAVING

REFERENCE 1 - FULL NAME (Professional Only) *

First

Last

REFERENCE 1 RELATIONSHIP *

REFERENCE 1 COMPANY *

REFERENCE 1 TITLE *

REFERENCE 1 E-MAIL *

REFERENCE 1 PHONE *

REFERENCE 2 - FULL NAME (Professional Only)

First

Last

REFERENCE 2 RELATIONSHIP

REFERENCE 2 COMPANY

REFERENCE 2 TITLE

REFERENCE 2 E-MAIL

REFERENCE 2 PHONE

REFERENCE 3 - FULL NAME (Professional Only)

First

Last

REFERENCE 3 RELATIONSHIP

REFERENCE 3 COMPANY

REFERENCE 3 TITLE

REFERENCE 3 E-MAIL

REFERENCE 3 PHONE

MILITARY SERVICE - ARE YOU A VETERAN?

BRANCH

RANK AT DISCHARGE

DATES OF SERVICE (FROM-TO)

TYPE OF DISCHARGE

IF NOT HONORABLE, PLEASE EXPLAIN

IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? *

DISCLAIMER: Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please fully complete in order for it to be considered. Please complete each section EVEN IF you decide to send a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. 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 agree

Please email a resume and any additional information you may believe helpful to executivedirector@elderhaus.org.

Other Comments

Find Us

Colorado Gives

Donate (Credit Card or PayPal)