Employment Form

* = Required Information

Date *

Last Name *

First Name *

Middle Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Social Security Number *

Telephone *

Cell Phone *

E-Mail Address

Referred to us by

Position applied for

Date available

Type of employment desired

Part-Time

PRN

Current Availability

I can work in the geographic area

Days Available

Desired Hours (daytime, evening, anytime)

Daytime

Evening

Anytime

If HHA or CNA, are you available for Bath Visits?

Yes

If currently employed, may we contact your employer?

Yes

Rate of Pay Expected

Comments

Are you legally eligible for employment in the US?

Yes

Are you available to work Call Outs, if needed?

Yes

Have you been employed at this company before?

Yes

When?

and at what location?

Do you have any friends or family employed at this location?

Yes

Have you been convicted of a crime in the last seven (7) years?

Yes

If yes, please explain
CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT.

If considered for hiring, will you agree to provide a criminal background check?

Yes

If considered for hiring, will you agree to provide a Motor Vehicle Record?

Yes

N.A.

EDUCATIONAL BACKGROUND

List previous three (3) educational institutions attended, beginning with the most recent.

School

City, State/Province

Graduated?

Yes

Degree(s) / Diploma(s) Earned

School

City, State/Province

Graduated?

Yes

Degree(s) / Diploma(s) Earned

School

City, State/Province

Graduated?

Yes

Degree(s) / Diploma(s) Earned

License Valid in State of Georgia

Type

Date of Most Recent Registration

Valid in State of Georgia?

Yes

Type

Date of Most Recent Registration

Valid in State of Georgia?

Yes

Do you have the following:

CPR

Yes

Expires

First Aid

Yes

Expires

Yes

Expires

Please answer the following questions

What do you think is the most difficult part of nursing or customer service work?

What was the best job you ever had and why?

What was your least favorite job and what did you dislike about it?

Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?

Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?

How will you be able to contribute to providing seniors with high quality care?

EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.

Employer

Telephone

Dates Employed
From

Address

Job Title

Hourly Rates/ Salary
Starting

Per

Final

Per

Immediate Supervisor

Title

Phone Number

May we contact for reference?

Yes

Summarize the type of work performed and job responsibilities

Reason for leaving

Employer

Telephone

Dates Employed
From

Address

Job Title

Hourly Rates/ Salary
Starting

Per

Final

Per

Immediate Supervisor

Title

Phone Number

May we contact for reference?

Yes

Summarize the type of work performed and job responsibilities

Reason for leaving

Employer

Telephone

Dates Employed
From

Address

Job Title

Hourly Rates/ Salary
Starting

Per

Final

Per

Immediate Supervisor

Title

Phone Number

May we contact for reference?

Yes

Summarize the type of work performed and job responsibilities

Reason for leaving

Employer

Telephone

Dates Employed
From

Address

Job Title

Hourly Rates/ Salary
Starting

Final

Immediate Supervisor

Title

Phone Number

May we contact for reference?

Yes

Summarize the type of work performed and job responsibilities

Reason for leaving

REFERENCES

Name

Relationship

Years Acquainted

Phone Number

Name

Relationship

Years Acquainted

Phone Number

EMERGENCY CONTACT

Name

Number

Relation

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 provide criminal background check at my cost, proof of identity and legal authority to work in Georgia, proof of certifications or educational qualifications, and a driver abstract (if applicable).
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

Clear if the signature is not legible

Phone Number