APPLICATION FOR EMPLOYMENT

Name:                                                                                                                                      

                 Last                                     First                                                      Middle Initial

Address:                                                                                                                                  

                  Street                                         City                                              Zip

Phone Number                                                               Social Security Number

Position applying for                                                       Desired Salary

What experience do you have?

Previous Employer                                                                          How long at previous job?

                        DL Number                                                                                                                    

Do you have a Valid SC Drivers License?                         Date of Birth

SIGNING OF THESE SECTIONS IS AN AGREEMENT BETWEEN CMS OF SC INC. AND EMPLOYEES

CMS of SC Inc. will not require anyone to work more than a 40 hour work week. Anyone wanting to work more than 40 hours a week will be paid at their regular hourly rate only.

CONSENT FOR DRUG / ALCOHOL SCREEN TESTING

In the interest of safely for all concerned, you may be required to take a urine test for drug and / or alcohol use. Following any accident or injury you shall be tested for drugs and / or alcohol.

I have been fully informed for the reasons for this urine test for drugs and / or alcohol (I understand what I am being tested for), the procedure involved, and do hereby freely give my consent. I may at anytime be asked to submit a urine sample for testing. In addition I understand that the results of this test will be forwarded to my employer and become part of my record.

I hereby authorize these test results to be released to CMS of SC Inc.

Signature of Employee                                                   Date

Signature of CMS of SC Inc. Supervisor                           Rate of Pay

SUBMIT