Basic Info Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact * First Name Last Name Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Relationship * Spouse Parent Child Friend Sibling Other Relative Position & Background I am applying for a position as a: * PCA (Personal Care Aide) CNA (Certified Nursing Assistant) RN (Registered Nurse) Office Staff Have you ever been convicted of a felony? * Yes No Transportation Do you have dependable transportation? * Yes No Availability Number of hours you'd like to work Times you are available to work * Select all that apply 1st Shift (7am-3pm) 2nd Sift (3p-11pm) 3rd Shift (11pm-7am) Can you be called last minute? * Yes No Comments Education Highest Level of Education completed * High School (Did Not Graduate) HS Diploma or equivalent Some College Associate Degree (AA/AS) Bachelor's Degree (BA/BS) Master's Degree (MA/MS/MBA/MHA) Doctorate/ Professional Degree (PhD, MD, JD, etc.) Vocational/ Technical/ Trade School Certificate Program Other Training/ Continuing Education Skills Checklist * Companionship Bathing/ dressing Grooming Incontinence Transfer Assist Vacuuming Dusting Clean Bathrooms Clean Kitchen Bed linen changes Laundry Grocery shopping Cooking Driving Medication reminders Preferred Start Date MM DD YYYY How did you hear about us? * Friend/ Family Employee Social Media Online Search Other (please specify) CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. Electronic Signature * Date MM DD YYYY Thank you! Let’s work together
