Join Our Team Application for Employment Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone # * (###) ### #### DOB * Email * Social Security Number * Position(s) applied for * Caregiver Nursing Other Date available * MM DD YYYY Type of employment desired * Full-Time Part-Time Casual This position requires flexible availability to include overnight. Please provide days and times you are unavailable: * If currently employed, may we contact your employer? * Yes No Rate of Pay Expected Have you ever been employed as a caregiver? * Yes No Are you legally eligible for employment in this country? * Yes No Do you have any physical or mental disabilities? * Yes No Do you have any disability or injuries that would prevent you from performing duties as a care giver? * Yes No Are you available to work overtime if required? * Yes No Have you been employed at this company before? * Yes No Do you have any friends or family employed with our Company? * Yes No Have you been convicted of a crime in the last seven (7) years? * Yes No Do you have and pending criminal charges against you? * Yes No If considered for hiring, will you agree to undergo a criminal background check and drug screening? * Yes No If considered for hiring, will you agree to provide a driver’s license? * Yes No EDUCATIONAL BACKGROUND * List previous three educational institutions attended, beginning with high school. List 2 Relevant certifications, training, and licenses * Do you have the following: * CPR Yes No * First Aid Yes No * CNA Yes No EMPLOYMENT BACKGROUND * Provide the following information beginning with the most recent employer. DATES EMPLOYED * FROM - TO HOURLY RATE/SALARY * Starting & Final HOURLY RATE/SALARY * Starting & Final MAY WE CONTACT FOR REFERENCE? Yes No Later SUMMARIZE JOB RESPONSIBILITIES * EMPLOYMENT BACKGROUND * Provide the following information beginning with the most recent employer. DATES EMPLOYED * FROM - TO HOURLY RATE/SALARY * Starting & Final MAY WE CONTACT FOR REFERENCE? Yes No Later SUMMARIZE JOB RESPONSIBILITIES * EMPLOYMENT BACKGROUND * Provide the following information beginning with the most recent employer. DATES EMPLOYED * FROM - TO HOURLY RATE/SALARY * Starting & Final MAY WE CONTACT FOR REFERENCE? Yes No Later SUMMARIZE JOB RESPONSIBILITIES * REFERENCES * List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please). I certify that all the information I have provided is true, complete and correct. The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified. I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal. I understand that if I am hired, I will be required to undergo a criminal background check and drug screen, and provide proof of identity, certifications and/or educational qualifications. Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment. * Applicant’s Signature Date Thank you for your interest in joining our team. Your application has been successfully submitted and will be reviewed by our hiring team. If you are selected for the next steps, we will contact you shortly.
