Attain and Gain Application

APPLICATION FOR EMPLOYMENT
Attain and Gain Counseling LLC is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law.
INTRODUCTORY INFORMATION:

Your General Information
Name*
Date*

MonthDayYear
Date
Address*
City*
State*
Zip*
Phone*
Social Security Number*
Email*
example@example.com
CDS Login: (First Initial, Last Name, Last 4 digits of SSN
Type of work desired*
Salary desired*
Date Available*

MonthDayYear
Date
APPLICANT QUESTIONS:
If hired, can you provide documents required to establish your eligibility to work in the U.S.?*

YesNo
Are you 18 years of age or older?*

YesNo
How were you referred to Attain and Gain?*
Which languages do you speak?*
Have you ever been convicted or pled guilty or no contest to, a crime other than a minor traffic violation?*

YesNo
If yes, please explain in detail on a separate piece of paper and include the date of final disposition of the case and the nature of the offense. This information will not necessarily disqualify you from employment but false or misleading information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.
EDUCATION:
Name & Address of School*
Course of Study*
If High School only use 'N/A'
Number of years completed*
Degree/Diploma*
Other Education, Training or Certifications
Name & Address of School
Course of Study
Number of years completed
Degree/Diploma
Name & Address of School
Course of Study
Number of years completed
Degree/Diploma
Cert No
Date

MonthDayYear
Date
Licensure/Certifications: (please attach)

Cancelof
MILITARY EXPERIENCE:
Branch of Service
From
To
Rank/Type of Service: Job-Related Training/Experience:
Rank/Type of Service
Job Related Training/Experience
Record of Employment

List Positions starting with the most recent
Employer #1
Telephone
Address
Position Title
Supervisor
Start Date

MonthDayYear
Date
Date Left

MonthDayYear
Date
Beginning Salary
Ending Salary
Duties
Reason for Leaving
Employer
Telephone
Address
Position Title
Supervisor
Start Date

MonthDayYear
Date
Date Left

MonthDayYear
Date
Beginning Salary
Ending Salary
Duties
Reason for Leaving
Employer
Telephone
Address
Position Title
Supervisor
Start Date

MonthDayYear
Date
Date Left

MonthDayYear
Date
Beginning Salary
Ending Salary
Duties
Reason for Leaving
PROFESSIONAL REFERENCES: (Do not include relatives)
Professional References #1
Name

First NameLast Name
Occupation
Years Known
Contact Information
Professional References #2
Name

First NameLast Name
Occupation
Years Known
Contact Information
Driver's License*

Cancelof
Social Security Card*

Cancelof
First Aid/CPR (Required Before Starting Work)

Cancelof
High School Diploma (Required Before Starting Work)

Cancelof
COVID-19 Vaccination Card*

Cancelof
STATEMENT (Please read this statement carefully before signing this application): I understand that employment with Attain and Gain (the Organization) is at-will, meaning that or the Organization may terminate my employment at any time, or for any reason consistent with applicable state or federal law. I authorize the Organization to conduct a thorough criminal background investigation of my work and personal history, and verify all data given on this application and during interviews. This includes the completion of a Medicaid Fraud background check. hereby release the Organization, and its representatives or agents, from any liability that might result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested information and release them from all liability for providing the requested information. - understand that the Organization may require the successful completion of a drug and/or alcohol test as a condition of employment. I understand this application will be active for a period of 90 days; after that time, if wish to be considered for employment, - must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.
Signature of Applicant*

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

APPLICATION FOR EMPLOYMENT

INTRODUCTORY INFORMATION:

APPLICANT QUESTIONS:

EDUCATION:

MILITARY EXPERIENCE:

Record of Employment