Language
English (US)
EMPLOYMENT APPLICATION
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email Address
*
example@example.com
Position Applying For
*
Please Select
Home Care Assistant
Certified Nurse Assistant
Licensed Practical Nurse
Registered Nurse
Office Assistant
Marketing Associate
Date Available to Start
*
-
Month
-
Day
Year
Date
Desired Salary
*
Per Hour Rate
Are you a citizen of the United States?
*
YES
NO
If no, are you authorized to work in the United States?
*
YES
NO
N/A
Have you ever worked for this company?
*
YES
NO
If so, please indicate when.
EDUCATION HISTORY
Name of High School
*
Address of High School
Dates Attended High School (From-To)
*
Did you graduate?
*
YES
NO
Name of College
Address of College
Dates Attended College (From-To)
Did you graduate?
YES
NO
Other Education/Training
Location/Address of Education/Training
Dates Attended College (From-To)
PROFESSIONAL LICENSURE/CERTIFICATION
Type of License/Certification
License/Certificate#
State Issued
Type of License/Certification
License/Certificate#
State Issued
EMPLOYMENT HISTORY
Employer Name
*
Employer Address
*
Employer Phone Number
*
Please enter a valid phone number.
Employer Contact/Supervisor Name
*
Your Job Title
*
Your Starting Salary
*
Per Hour Rate
Your Current or Ending Salary
*
Per Hour Rate
Duties & Responsibilities
*
Dates of Employment (From - To)
*
If currently employed, indicate From - Present.
Currently Working Here?
*
YES
NO
Reason for Leaving (If currently working here, enter N/A.)
*
May we contact this employer for a reference?
*
YES
NO
Employer Name
*
Employer Address
*
Employer Phone Number
*
Please enter a valid phone number.
Employer Contact/Supervisor Name
*
Your Job Title
*
Your Starting Salary
*
Per Hour Rate
Your Current or Ending Salary
*
Per Hour Rate
Duties & Responsibilities
*
Dates of Employment (From - To)
*
Currently Working Here?
*
YES
NO
Reason for Leaving (If currently working here, enter N/A.)
*
May we contact this employer for a reference?
*
YES
NO
REFERENCES (*Do Not Use Family Members)
Full Name of Professional Reference
*
First Name
Last Name
Place of Employment
*
Position/Relationship
*
Phone Number
*
Please enter a valid phone number.
Number of Years Known
*
Full Name of Professional or Character Reference
*
First Name
Last Name
Place of Employment
*
Position/Relationship
*
Phone Number
*
Please enter a valid phone number.
Number of Years Known
*
Full Name of Professional or Character Reference
*
First Name
Last Name
Place of Employment
*
Position/Relationship
*
Phone Number
*
Please enter a valid phone number.
Number of Years Known
*
BACKGROUND HISTORY/SCREENING
Have you ever pled guilty, no contest or convicted of a crime?
*
YES
NO
If YES, in the section below, please disclose all criminal convictions, findings of guilt, pleas of guilty to a misdemeanor or felony charge, any suspended imposition of sentence, any suspended execution of sentence, any period of probation or parole, or pleas of no contest excluding minor traffic offenses. If NO, you must enter N/A.
*
Will you consent to a criminal record check?
*
YES
NO
Will you consent to a closed record check?
*
YES
NO
Are you currently listed on the EDL (Employee Disqualification List).
*
YES
NO
Have you ever used any other names, aliases or social security numbers?
*
YES
NO
If you answered YES to using other names, aliases or social security numbers, please list below. If NO, you must enter N/A.
*
SKILLS & PREFERENCES
Tell us about your caregiving experiences.
*
Check all skills you have experience with:
*
COVID-19 Positive Client
Alzheimer's/Dementia
Transfer Assistance
Gait Belt
Hoyer/Standing Lift
Bathing Assistance
Total Care / Bed Bound Client
Incontinence Care
Client Transportation in Automobile
Assistance with Feeding Client
N/A
Other
Check the following you prefer to NOT work with:
*
Dogs
Cats
Smokers
Alzheimer's/Dementia Client
N/A
Other
ADDITIONAL QUESTIONS
Do you have reliable transportation to work?
*
YES
NO
How did you hear about us?
*
CERTIFICATION AND RELEASE
I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize Care Solutions In-Home Services LLC to verify any and all information contained within this application, 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 and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
RESTRICTIVE COVENANT
I agree to not do business directly with any individual or business entity that Care Solutions In-Home Services LLC has introduced to me or enter into employment agreement with such individuals or business.
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
Save
Submit
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