Employment Application
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indicates required fields
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Full Name:
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Date: MO/Day/Year:
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Present Address:
Previous Address:
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Home Phone #:
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How did you hear about us?:
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Date of Birth MO/DAY/Year:
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Highest Level of Education:
High School
College
Trade School
Some High School
Some College
Other
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School Name and Location:
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Check All Which Apply to You:
I am a CERTIFIED Caregiver.
I am a CNA in good standing.
I have been convicted of a crime.
I am awaiting trial.
I have my CPR certification.
I have my First Aid certification.
I have my Food Handler's card.
I have been fingerprinted.
None of the Above.
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Who was your last employer? Your position?:
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Why did you leave?:
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Please check if we may contact your last employer:
Yes, you may contact my former employer.
No, do not contact them.
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If you checked above, please provide phone number:
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Please check shifts that you are willing to work:
First
Second
Third
Weekends preferred
Weekdays preferred
Split Shifts w/ extra pay
Days PT
Evenings PT
On-call staff
Other
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What is your desired salary?:
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How many days did you miss at your last job?:
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Finally, please verify job applying for:
Caregiver
Care Manager
Server
Cook
Management
Business Office
Housekeeping
Maintenance
Volunteer
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I certify that facts in this application are true:
Yes, this application is accurate to the best of my knowledge.
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List Reference with phone number ________________:
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List Reference with phone number _________________:
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List Reference with phone number:
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