Employment Application Online Employment Application Residential Care Provider application We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientations, citizenship status, or any other legally protected status.Position(s) Applying for:*PERSONAL INFORMATIONName Last First Middle Maiden Present Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* If you are under 18 years of age, can you provide proof of your eligibility to work? YES NO Have you ever filed an application with us before?* YES NO Approximate Date of Previous Application. Date Format: MM slash DD slash YYYY Do any of your friends or relatives work for Eastco?* YES NO Name of friend/relativeFirst NameLast Name Are you currently employed?* YES NO May we contact your present employer?* YES NO In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.Date Available to Work* Date Format: MM slash DD slash YYYY What is your salary range?*Are you available to work?* Full Time Part Time Temporary Can you travel if a job requires it?* YES NO EDUCATIONHIGH SCHOOLName of School / LocationCourse or StudyYears CompletedDiploma: YES or NO COLLEGEName / LocationCourse of StudyYears CompletedDiploma: YES or NO BUSINESS OR TRADE SCHOOLName / LocationCourse of StudyYears CompletedDiploma: YES or NO PROFESSIONAL OR GRADUATE SCHOOLName / LocationCourse of StudyYears CompletedDiploma: YES or NO Describe any specialized training, apprenticeship, skills and extra-curricular activities.Describe any job-related training received in the United States military.WORK EXPERIENCEStart with your present or last job. Include any job-related military service assignments and volunteer activities.EMPLOYER 1Name of EmployerCity, State, ZIPPhone Number Name of SupervisorEmployment DatesLast Job Title Reason for leaving. Be specific.List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.EMPLOYER 2Name of EmployerCity, State, ZIPPhone Number Name of SupervisorEmployment DatesLast Job Title Reason for leaving. Be specific.List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.EMPLOYER 3Name of EmployerCity, State, ZIPPhone Number Name of SupervisorEmployment DatesLast Job Title Reason for leaving. Be specific.List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.REFERENCESPlease list below three persons not related to you who have knowledge of your work performance and/or personal qualifications within the last 5 years.PROFESSIONALNameOccupationCompany NameAddressPhoneEmailYears Acquainted PROFESSIONALNameOccupationCompany NameAddressPhoneEmailYears Acquainted PERSONALNameOccupationCompany NameAddressPhoneEmailYears Acquainted APPLICATION FORM WAIVERPlease read each paragraph closely, check the box next to each paragraph and sign below.* I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or any other document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize Eastco Diversified Services to thoroughly investigate my references, work records, education, driving record, credit history, criminal background and other matters related to my suitability for employment. I further authorize the employers, schools and other references I have listed to disclose to Eastco Diversifed Services any and all documents, transcripts, letters, reports and other information related to these references, without giving me prior notice of such disclosure. I understand that nothing contained in the application, or conveyed during any interview which may be granted, or during my employment, if hired, is intended to create an employment contract between me and Eastco Diversified Services, other than one that is at will. I understand and agree that if I am employed, my employment will be of an at will nature, whereby either the employee or the employer may terminate the employment relationship at any time, with or without cause or notice. I further understand that my employment, if hired, is for no definite or determinable period of time and may be terminated at any time, at the option of either myself or Eastco Diversified Services, and that no promise or representation contrary to the foregoing is binding on the company unless made in writing and signed by me and the company's designated representative. Type Name for Signature*Date* Date Format: MM slash DD slash YYYY Eastco Diversified Services is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with Eastco Diversified Services depends solely on your qualifications. Thank you for completing this application form and for your interest in our business.