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How to Write a Medical POA. Download in Adobe PDF (.pdf), Microsoft Word (.docx), or Open Document Text (.odt). Step 1 – In Section I (Appointment of Health Care Agent) the principal and Agent full name and address. At the bottom of the section, the home phone, work phone, cell phone, and e-mail of the agent should be written.

A job application allows an individual to enter their personal details to apply for employment. After completing, it will provide the employer a snapshot of the applicant’s availability, education, and past work experience. The applicant may be required to authorize a declaration that certifies the information provided is true and accurate.

Background Check Consent – Use if the employer would like to conduct a background check to verify if the applicant has a criminal past (not legal in some jurisdictions).

Download inAdobe PDF, Microsoft Word (.docx) or Open Document Text (.odt).

Part I. Personal Information

(1) Applicant Name. The Job Applicant, who will submit this application, will need to be identified at the beginning of this process. His or her name is expected in the standard presentation of “First,” “Middle,” and “Last” where requested.

(2) Current Date.

(3) Address. The Job Applicant’s residential address must be distributed to the next area. Two lines are provided for this purpose. It is inadvisable to use a P.O. Box address unless absolutely necessary. Most if not all Employers will need the home address of each potential Employee to support a background check.

(4) E-Mail Address. The Job Applicant should be able to provide a valid email address that is actively monitored.

(5) Telephone Number. Many potential Employers will contact the Applicant by telephone for important matters, questions, or decisions. The Job Applicant’s cell phone and/or home phone number(s) should be displayed with his or her other contact information.

(6) Social Security Number. A generally accepted and extremely reliable means of verifying one’s identity is his or her social security number. Therefore, a specific area has been reserved for the Job Applicant’s social security number to be displayed.

(7) Date Available. The calendar date when the Job Applicant is first able to physically work should be reported.

(8) Desired Pay. The pay rate that is expected by the Job Applicant can be defined as a dollar amount paid by the hour or a set yearly salary. The production of this information should be made as a dollar amount followed by either the “Hour” or “Salary” checkbox selected.

(9) Employment Desired.

(10) Employment Status Sought. It should be indicated whether the Job Applicant seeks “Full-Time,” “Part-Time,” or “Seasonal” employment. If the Job Applicant is flexible, then any combination of these checkboxes can be selected so long as it matches the Job Applicant’s intention.

Part II – Employment Eligibility

(11) Legal Eligibility To Work. The ability to legally work in the United States should be one of the Job Applicant’s qualities. If so, the “Yes” box should be marked or selected. Otherwise, if the Job Applicant is unable to legally work in the United States (i.e. he or she may require Sponsorship), the “No” box should be selected.

(12) Previous History With Employer. The “Yes” box should be selected if the Job Applicant has worked for the Employer accepting this application. If not, then the “No” box should be marked. Bear in mind that if the Job Applicant has worked for this Employer before then a production of the first calendar date and the last calendar date of his or her term of employment with this Employer must be included in this section.

(13) Criminal Status. The criminal history of the Job Applicant will need to be established. If he or she has never been convicted of a (felony) crime then the “No” box must be chosen. If not, then the “Yes” box should be checkmarked or selected and a discussion of the nature of the conviction on the circumstances that led to the conviction as well as its result will need to be documented.

Part III – Education

(14) High School. A brief history of the Job Applicant’s academic history is required for this application. Thus, the name of the high school that he or she attended should be supplied along with the city and state where it is located.

(15) Dates Attended. The first and last calendar dates when the Job Applicant attended the named high school are needed.

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(16) Completion Status. The “Yes” box should be marked if the Job Applicant graduated from high school and the degree he or she earned should be dispensed. If the Job Applicant did not graduate high school then the “No” box should be marked.

(17) College. If the Job Applicant attended college then the full name of this college or university should be on display along with the city and the state where it can be found.

(18) Dates Attended. Both the first date of the term the Job Applicant attended college and the final date of his or her attendance will be needed in this section.

(19) Degree Status. If the Job Applicant is a College graduate, then the box labeled “Yes” must be selected and the degree he or she earned should be selected. Otherwise, if he or she did not earn a degree, then the “No” box must be marked.

(20) Other Educational Facilities Or Courses. A record of any other type of education attained by the Job Applicant should be included. For instance, if the Job Applicant attended a trade school, the name of the school along with the city, state, the dates attended, and the degree or certification obtained by the Job Applicant should be dispensed for review.

(21) Start Date And Final Date Of Attendance.

(22) Degree Or Certificate Granted. The certificate that the Job Applicant earned at the other Education Facility or Course attended is required to complete this area.

Part IV – Previous Employment

(21) Employer 1. Most Employers will wish to review the employment history of the Job Applicant. Therefore, the name of the last Company or Individual the Job Applicant worked for should be documented.

(22) Contact Information. The email address, telephone number, and the address where the Job Applicant’s last Employer can be contacted is required.

(23) Starting Pay. The starting pay is the pay rate the Job Applicant’s last Employer paid him or her when he or she first started working. Furnish this dollar amount then indicate if it is an hourly rate or a yearly salary by marking the appropriate checkbox.

(24) Ending Pay. The pay rate applied to the Job Applicant’s work by his or her Employer at the end of his or her employment must be on display as well as an indication as to whether this is an hourly pay rate or a salary.

(25) Job Title. The name of the position the Job Applicant held with his or her previous Employer should be produced for review.

(26) Responsibilities. The Job Applicant’s work duties or obligations should be documented.

(27) Term Of Employment. The first and last dates of the Job Applicant’s employment with his or her last Employer should be furnished to this section to conclude the requested report.

(28) Reason For Leaving. The basis for why the Job Applicant and this Employer are separated must be dispensed.

(29) Employer 2 Name And Contact Information. In addition to the last Employer the Job Applicant worked for, the second to last Employer should be presented. This process begins with the Second-to-Last Employer’s name and contact information.

(30) Starting And Ending Pay. The pay rate first earned by the Job Applicant with the Second-to-Last Employer should be recorded numerically and one of the checkboxes (“Hourly” or “Salary”) must be selected to define how often the Job Applicant was paid this dollar amount.

(31) Job Title And Responsibilities. The formal title of the Job Applicant’s position with his or her Second-to-Last Employer as well as the obligations or responsibilities the Job Applicant was responsible for must be produced.

(32) Term Of Employment. The dates when the Job Applicant worked for his or her Second-to-Last Employer should be defined as the first calendar date he or she worked and the last calendar date of work.

(33) Reason For Leaving. The Job Applicant should discuss why he or she left the position held with the Second-to-Last Employer or why his or her work contract terminated with this Entity.

(34) Employer 3 Name And Contact Information. A final discussion is expected regarding the Second-to-Last Employer of the Job Applicant. A record of the name, email address, business telephone number, and street address of Employer 3 should be documented where requested.

(35) Starting And Ending Pay. The amount earned by the Job Applicant with Employer 3 when he or she was hired should be presented as a dollar amount that was paid every hour or as a yearly salary (indicate which by choosing the “Hourly” box or the “Salary” box). Additionally, the pay rate earned by the Job Applicant with Employer 3 on his or her last day of work should also be presented where needed.

(36) Job Title And Responsibilities. The Job Applicant’s work with Employer 3 should be furnished to this area.

(37) Term Of Employment. A record of the first and last calendar dates of the Job Applicant’s work with Employer 3 must be displayed.

(38) Reason For Leaving. The final presentation required by this section will be the reason the Job Applicant and Employer 3 terminated their work relationship.

Part V – References

(39) Full Name And Relationship Of Reference. The potential Employer accepting this application for review may wish to review the past employment history of the Job Applicant. This often requires that the Job Applicant’s professional references are listed. Beginning with a production of the name of the Job Applicant’s Reference Person along with a description of their relationship.

(40) Company And Title Held By Reference. The name of the Company the First Reference works for and the title he or she holds there should be presented.

(41) Contact Information. The First Reference’s contact information should be provided beginning with his or her email address and phone number.

(42) Full Name And Relationship Of Second Reference. The name of the Second Reference should be dispensed along with a record of how he or she is related to the Job Applicant.

(43) Company And Title Held By Second Reference. In most cases, a potential Employer will seek more than one Reference. The Company name of the Entity works and the name of the position held by the Second Reference is needed for this area.

(44) Contact Information. The Second Contact’s email address and phone number will be required for this application.

(45) Third Reference. The Job Applicant’s Third Reference should be identified by name, have his or her relationship to the Job Applicant reported, and his or her contact information produced.

Part VI – Military Service

(46) Veteran Status. The first checkbox in the “Military Service” section should be selected if the Job Applicant has served in a branch of the military. If not, then the box corresponding to the label “No” should be selected.

(47) Branch And Rank. If the Job Applicant served in the military, then the branch that he or she served in and the rank he or she held at the point of discharge must be presented.

(48) Term Of Service. A production of the dates when the Job Applicant enlisted and the date when he or she was discharged to military service is required.

(49) Type Of Discharge. Report the discharge status of the Job Applicant. If he or she was not discharged honorably, then an explanation should be displayed in the available area.

Part VII – Background Check Consent

(50) Background Check. The Job Applicant must indicate if he or she will consent to a background check. The consent section will allow this permission to be delivered when the Job Applicant selects the “Yes” box and signs this paperwork. Otherwise, if the Job Applicant will not consent to a background check performed by the Employer.

Part VIII – Disclaimer

(51) Job Applicant Signature. This application will only be considered a valid submission of information if the Job Applicant signs his or her name.

(52) Signature Date Of Job Applicant. The calendar date when the Job Applicant signed this form should be dispensed once he or she signs it.

(53) Printed Name.

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