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Name: *
Name:
Address: *
Address:
Date of Birth: *
Date of Birth:
Home Phone Number:
Home Phone Number:
Cell Phone Number:
Cell Phone Number:
Do you have a valid driver's license? *
Emergency Contact Telephone Number: *
Emergency Contact Telephone Number:
Date can start: *
Date can start:
Address of High School: *
Address of High School:
Graduation Date:
Graduation Date:
Address of College Attended?
Address of College Attended?
College Graduation Date?
College Graduation Date?
Current Employer or Most Recent: *
Current Employer or Most Recent:
Company Phone Number: *
Company Phone Number:
Company Mailing Address: *
Company Mailing Address:
Supervisor's Name: *
Supervisor's Name:
Company/Employer Name (second most recent): *
Company/Employer Name (second most recent):
Company Phone Number: *
Company Phone Number:
Company Mailing Address: *
Company Mailing Address:
Supervisor's Name: *
Supervisor's Name:
Company/Employer Name: *
Company/Employer Name:
Company/Employer Phone Number: *
Company/Employer Phone Number:
Company Mailing Address: *
Company Mailing Address:
Supervisor's Name: *
Supervisor's Name:
Signature of Applicant *
Signature of Applicant
The information provided in this application for employment is true and complete. If employed, any misstated or omission of fact of this application may result in my dismissal. I understand that the acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I hereby authorize the release of information from any organization relevant to certification of past employment or education (release of information) of the above named individuals to Charles County HARC, Inc.
Date signed: *
Date signed:

Charles County HARC, Inc. is an equal opportunity employer promoting a drug free, smoke free workplace.

Charles County HARC, Inc. is an equal opportunity employer dedicated to a policy of non-discrimination in employment including race, creed, color, age, sex, religion, national origin, and disability. This agency is licensed by the Maryland Department of Health and Mental Hygiene, which is in compliance with regulations relevant to terms of employment. It is the intent of this application to secure information necessary to comply with these requirements.

Lauren Constantine