TE Miller Development, LLC is an equal opportunity employer and encourages diversity in employment. The Company makes all hiring decisions without regard to an applicant’s race, religion, sex, age, national origin, sexual orientation, disability or other protected classification under federal, state or local equal opportunity laws.

*denotes required fields

*Full Name

*Date

Previous Name, Maiden Name or Alias

Current Address

*Street

*City/State

*Zip Code

Previous Addresses (list for past 10 years)

(1) *Address

*City/State

*Zip Code

Date residing at this address:


(2) Address

City/State

Zip Code

Date residing at this address:


(3) Address

City/State

Zip Code

Date residing at this address:


*Social Security Number

Are you at least 18 years of age? YesNo

*Home Phone Number

Work Phone Number


Driver's License

*State

*License Number

Are you authorized to work in the United States on an unrestricted basis?
YesNo

Have you worked for TE Miller Development or an affiliated company before?
YesNo

If yes, specify the position, company and date


Employment Desired

*Position

*Wages Desired

*Date Available

*Hours Preferred

*Days/Times Available

Are you willing to work overtime if necessary?
YesNo

*How did you learn of this opening?


Qualifications

The use of illegal drugs is absolutely prohibited under Company policy. Where allowed by applicable law, the Company may require employees to submit to drug testing as a condition of continued employment.

Do you possess a valid driver’s license?
YesNo

Have you received three or more traffic violations in the last 3 years?
YesNo

Has your driver’s license been suspended or revoked in the last 3 years?
YesNo

Have you ever been convicted of or pled guilty to a felony?
YesNo

Have you ever been convicted of or pled guilty to a crime involving the abuse, neglect or exploitation of a child or adult?
YesNo

Explan all YES answers above:


Education

High School/GED (Degree, Name of School, Address, Major)

Technical/Vocational (Degree, Name of School, Address, Major)

College/University (Degree, Name of School, Address, Major)

Other (Degree, Name of School, Address, Major)


Specialized Training, Certification of Experience

First Aid (include expiration date & any additional comments)

CPR (include expiration date & any additional comments)

Other (include expiration date & any additional comments)

If applicable, list other languages spoken (non-English)

List any license or certification you possess that is relevant to the position you are applying for:


References

The Company requires that all applicants submit three (3) references, which may include: current or former employers, supervisors, teachers or others qualified to objectively evaluate your ability to work in the position for which you have applied. Please list the reference information identified below. The Company will be contacting each reference listed.

(1) *Name

(1) *Relationship to Applicant

(1) *Address

(1) Fax Number

(1) *Daytime Phone Number

(1) *Nighttime Phone Number


(2) *Name

(2) *Relationship to Applicant

(2) *Address

(2) Fax Number

(2) *Daytime Phone Number

(2) *Nighttime Phone Number


(3) *Name

(3) *Relationship to Applicant

(3) *Address

(3) Fax Number

(3) *Daytime Phone Number

(3) *Nighttime Phone Number


Work History

If you are currently employed, may we contact your employer?
YesNo

Begin with current or most recent employer or position with employer:

(1) Employer

(1) Address

(1) Supervisor

(1) Phone Number

(1) Dates of Employment

(1) Ending Wage

(1) Position

(1) Description of Job

(1) Reason for leaving


(2) Employer

(2) Address

(2) Supervisor

(2) Phone Number

(2) Dates of Employment

(2) Ending Wage

(2) Position

(2) Description of Job

(2) Reason for leaving


(3) Employer

(3) Address

(3) Supervisor

(3) Phone Number

(3) Dates of Employment

(3) Ending Wage

(3) Position

(3) Description of Job

(3) Reason for leaving


(4) Employer

(4) Address

(4) Supervisor

(4) Phone Number

(4) Dates of Employment

(4) Ending Wage

(4) Position

(4) Description of Job

(4) Reason for leaving


(5) Employer

(5) Address

(5) Supervisor

(5) Phone Number

(5) Dates of Employment

(5) Ending Wage

(5) Position

(5) Description of Job

(5) Reason for leaving


THANK YOU FOR YOUR INTEREST IN TE MILLER DEVELOPMENT

We at TE Miller Development are pleased you are interested in becoming a member of our Company. We are proud of our excellent reputation and the services we provide. We value diversity and want your work experience to be enjoyable. To help ensure a safe work environment and excellent services we carefully screen the background of all applicants. This screening may include an oral interview, as well as an investigation of your work history, driving record, application information, credit check and reference check. The Company requires that an investigation of your background for any criminal conduct be completed. Some service areas may also require a screening for the use of illegal drugs.

APPLICANT DECLARATION OF UNDERSTANDING

  • I understand that the Company may conduct an investigation of the information I have noted on this application or statements or other data obtained from me or from any other person pertaining to my employment history, credit, prior tendencies, character, general reputation, personal characteristics and mode of living. By signing this application, I hereby authorize the Company to use any consumer reporting agency, credit bureau or other investigative agencies to conduct this investigation and I release from all liability and hold harmless any person giving or receiving information about me relative to this investigation.
  • I understand that any falsification, misrepresentation or omission of information discovered as a result of this investigation may prevent my being hired or if hired, may subject me to the immediate termination of my employment with the Company.
  • I understand that this application process does not create an employment contract. All employment at the Company is “at-will.” This means, if the Company employs me, my employment is not for a specified or definite period of time and that I may resign or be discharged from my position at any time, for any reason, with or without cause or prior notice. I understand that the “at-will” policy listed above cannot be changed or amended without a formal written employment agreement signed by me and by a member of the Board of Directors of the Company.
  • I declare that I have never committed nor been charged or convicted of any act of abuse, neglect, exploitation or fraud in relationship to a dependent/vulnerable child or adult, within the past 10 years.
  • I declare that I have never knowingly violated any applicable rules or laws in any previous employment in residential, healthcare or similarly related employment.

By signing this application, I agree that I have read and understand the declarations listed above and I assert that all information given in this application is true.

*Digital Signature

*Date