Name:
Date:
Street Address:
City:
State:
Zip:
Phone Number:
Cell Number:
Email Address:
How did you hear about this opening?

LEGAL INFORMATION:

Are you legally authorized to work in the United States? Yes | No
If under the age of 18, can you provide the necessary work certificate at the time of employment? Yes | No
Have you ever been convicted of a crime, misdemeanor or felony? Yes | No
Have you ever been found to have committed elder or patient abuse, or have you ever been disciplined or terminated for elder or patient abuse? Yes | No
Would you agree to have a criminal background check? Yes | No

DRIVING INFORMATION:

Do you have a current valid driver’s license? Yes | No
Has your license ever been suspended or revoked? Yes | No
Do you have a reliable car for transporting clients? Yes | No
Are your auto insurance, registration and inspection valid and up-to-date? Yes | No
Would you agree to a DMV background check? Yes | No


AVAILABILITY:



Start date available:
Number of hours you desire:
Days/hours you are available to work:
Are you able to work:


EDUCATION:



High School: Graduated? Yes | No
Course of Study:
Technical School: Graduated? Yes | No
Course of Study:
College/University: Graduated? Yes | No
Course of Study:

Other education, training or special skills:


WORK EXPERIENCE:

Please list all previous employment, beginning with the most recent. If you need more room, you may attach another sheet of paper.

Employer:
Address:
From: To:
Position Held:
Reason For Leaving:

Supervisor's Name & Title:

May We Contact? Yes | No


Employer:
Address:
From: To:
Position Held:
Reason For Leaving:
Supervisor's Name & Title:
May We Contact? Yes | No


Employer:
Address:
From: To:
Position Held:
Reason For Leaving:
Supervisor's Name & Title:
May We Contact? Yes | No




REFERENCES:

 
Name:
Phone Number:

Email:

Address:
City:
State:
Zip:
Position or Title:
Years Known:


Name:
Phone Number:
Email:
Address:
City:
State:
Zip:
Position or Title:
Years Known:


Name:
Phone Number:
Email:
Address:
City:
State:
Zip:
Position or Title:
Years Known:
   

Authorization and Acknowledgements

I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for immediate termination of employment at any point in the future if I am hired.

I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

Signature: Check Box To Sign