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CLIENT CASE MANAGER JOB DESC
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Name
*
First
Middle
Last
Maiden Name and/or previous name(s):
First
Middle
Last
Address
*
Address Line 1
City
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State
Zip Code
Phone
*
Email
*
What position are you applying for:
How did you hear about the position?
Day Availability (Mark all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time of Day Available (Mark all that apply)
Morning
Afternoon
Evening
I am seeking a:
*
Full-time Job
Part-time Job
Seasonal / Temporary
How many hours can you work weekly?
Desired Wage:
*
Date available to begin:
Have you ever been employed by this company in the past?
*
Yes
No
I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work n the United State?
*
Yes
No
Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgement to a felony?
*
Yes
No
If Yes, please explain
Do you have a valid driver's license?
*
Yes
No
Driver's license number
*
Issued in what state?
*
Have you had any accidents during the past three years?
*
Yes
No
If yes how many?
Have you had any moving violations during the past three years?
*
Yes
No
If yes how many?
Education & Training
High School / GED
*
Course of Study
*
# of Years Completed
*
Did you Graduate?
*
Yes
No
Vocational Technical
Course of Study
# of Years Completed
Did you Graduate?
Yes
No
Degree Received
College and / or Graduate
Course of Study
# of Years Completed
Did you Graduate?
Yes
No
Degree Received
Skills & Qualifications
Describe and other Education, Training or Skills.
*
Military
Have you ever been in the Armed Forces?
Yes
No
Date entered:
Discharge date:
Are you now a member of the National Guard?
Yes
No
Specialty:
Work Experience
Employer 1
Address
Phone
Employment Start Date
Employment End Date
Starting Wage
End Wage
Name of last supervisor:
Hours worked per week:
Your last job title:
Reason for Leaving
List the jobs you held, duties performed, skills used or learned, etc.:
Employer 2
Address
Phone
Employment Start Date
Employment End Date
Starting Wage
End Wage
Name of last supervisor:
Hours worked per week:
Your last job title:
Reason for Leaving
List the jobs you held, duties performed, skills used or learned, etc.:
Employer 3
Address
Phone
Employment Start Date
Employment End Date
Starting Wage
End Wage
Name of last supervisor:
Hours worked per week:
Your last job title:
Reason for Leaving
List the jobs you held, duties performed, skills used or learned, etc.:
References
Name
*
First
Last
Phone
*
Email
*
Relationship
*
Name
*
First
Last
Phone
*
Email
*
Relationship
*
Name
*
First
Last
Phone
*
Email
*
Relationship
*
May we contact your present employer?
Yes
No
Authorization and Certification
PLEASE READ CAREFULLY BEFORE SIGNING:
I authorize investigation of all statements contained in this application and understand that misrepresentation or omission of facts called for is cause for rejection of this application or dismissal at a later date. Further, I understand and agree that my employment is for no definite period of time and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.
Applicant Signature
*
Clear Signature
Today's Date
*
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Ascend Services, Inc. is an equal opportunity employer.
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