Application for Care giver Aide

Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, ancestry, physical or mental disability, or veteran status.

Today's Date

Last name

First name

Middle initial

Street Address

City

State

ZIP

Telephone (home)

(cell)

E-mail

Are you 18 years old?

Yes

Have you ever been convicted of a felony?

Yes

Please explain

Are you a U.S. citizen or otherwise authorized to work in the U.S.?

Yes

Do you have a valid driver’s license?

Yes

Education

School Name and Location

Year

Major

School Name and Location

Year

Major

Degree

Other Training

Employment History: (Start with most recent employer, use additional page if necessary)

Company Name

Address

Telephone

Date Started

Starting Wage

Date Ended

Ending Wage

Name of Supervisor

May we contact?

Yes

Responsibilities

Reason for leaving

References

List three professional/personal references, not related to you, who have known you for more than one year

Name

Phone

Years Known

Address

Name

Phone

Years Known

Address

Emergency Contact

In case of emergency, please notify:

Name

Phone

Address

Name

Phone

Address

Please Read Before Signing:

I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application.

I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees.

I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.

Signature

Date

Application for Care giver Aide

Skills Inventory (check the areas in which you have experience or training):

Specialty

Tasks

Education

Employment History: (Start with most recent employer, use additional page if necessary)

References

Emergency Contact

Please Read Before Signing: