Part I: Personal Information

First Name *

Last Name *

Phone *

Secondary Phone Number

Email *

Part I: Personal Information

Street Address *

City *

State *

Zip Code *

Part I: Personal Information

How Long Have You Been At This Address?

Have you worked or attended school under another name?

List the other names you have worked or attend school under.

Are You 18 Years Old or Older?

Are you fully COVID-19 vaccinated?

Part 1: Personal Information

Are You Authorized to Work in the United States?

If hired, can you verify your legal right to work in the U.S.?

Have you ever been convicted of a crime?

Have you ever been terminated or asked to resign from employment?

If yes, please provide company name and details:

Part II: Desired Job Opportunity

What position are you applying for?

Do You Prefer Full-Time or Part-Time?

Are you currently employed?

May we contact your employers?

Available State Date:

Hourly Rate or Annual Salary Desired:

Part III: Availability

*Check all that apply, if required based on the position you are applying for.

Do You Have Reliable Transportation TO and FROM Work?

Are you available to work overtime?

What days are you available to work?

When are you available to work?

Which Categories Are You Available To Work?

Part IV: Education

Did you graduate from High School?

High School Name and Location:

Date of Graduation from High School:

Part IV: Education

Did you graduate from Technical School?

Technical School Name and Location

Degree Type Earned From Technical School:

Date of Graduation from Technical School:

Part IV: Education

Did you graduate from College or University?

College or University Name and Location

Degree Type Earned From College or University:

Date of Graduation from College or University:

Part IV: Education

List Locations / Dates / Degrees From Other Education Opportunities

Have You Served In The U.S. Military?

Please describe any relevant skills to the position you are applying for that you've acquired while serving in the US Military.

Part V: Licenses & Certifications

Do you have applicable Licenses, Certification or Credentials?

Practical Nurse License Number

Practical Nurse License Expiration Date

Registered Nurse License Number

Registered Nurse License Expiration Date

Part V: Licenses & Certifications

Select All The Paraprofessional Certifications You Hold:

HHA School or Training Program Name and Location

HHA Verification

Part V: Licenses & Certifications

CNA School or Training Program Name and Location

CNA Verification

PCA School or Training Program Name and Location

PCA Verification

Part VI: Employment History

Please list all previous employment, beginning with the most recent. Incomplete information could disqualify you from further consideration.

Former Employer #1 Company Name

Former Employer #1 Title/Position Held

Former Employer #1 Start Date

Former Employer #1 End Date

May We Contact Former Employer #1?

Part VI: Employment History

Former Employer #2 Company Name

Former Employer #2 Title/Position Held

Former Employer #2 Start Date

Former Employer #2 End Date

May We Contact Former Employer #2?

Part VI: Employment History

Former Employer #3 Company Name

Former Employer #3 Title/Position Held

Former Employer #3 Start Date

Former Employer #3 End Date

May We Contact Former Employer #3?

Part VII: References

Have you previously worked for Personal Caregiving Services

How did you hear about us?

Reference #1 Full Name

Reference #1 Phone Number

Reference #1 Relationship

Part VII: References

Reference #2 Full Name

Reference #2 Phone Number

Reference #2 Relationship

Reference #3 Full Name

Reference #3 Phone Number

Reference #3 Relationship

Authorizations

I represent that the answers and information given by me in the application are true and complete without qualification. I hereby authorize Personal Caregiving Services to verify the same and to make investigation of my background deemed necessary, including any credit check. I authorize former employers law enforcement organizations, educational institutions and any other third party to give Personal Caregiving Services any information they have regarding me without receiving written notice from them. I have no objection to making application for security clearance if necessary, signing an employee agreement on confidential information or taking medical examination. I understand that drug testing is a requirement for employment and Personal Caregiving Services may request a drug test at any tie during my employment in accordance with state and federal law. A positive test may result in termination from my employment. If terminated, I authorize the company to use any information I its possession concerning me for any purpose it deems appropriate including disclosure of information to any third party without notification to me of such disclosure and I release the company from any liability in connection with such use or disclosure.

Furthermore, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on the application may result in disciplinary action up to and including discharge from employment regardless of when discovered by Personal Caregiving Services.

I authorize investigation of all statements contained and the references listed above to give you any and all information concerning my previous employment pertinent information they may have personal or otherwise and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

Likewise, Personal Caregiving Services can terminate my employment at any time with or without cause, unless otherwise required by law. I further understand that no one other than Personal Caregiving Services has the authority to enter into an employment contract or agreement with me and that my at-will employment can be changed only by a written agreement.

I understand that by entering my information, I will be receiving a call and emails from a staff member of Personal Caregiving Services

I certify that the information contained in this application is true and complete. I attest to the fact that the answers given by me are correct to the best of my knowledge and ability.</p>

I certify that I have not knowingly withheld any information that might affect my chances of hiring.

I understand that any false information or omission (including any misstatement) on this application or on any document used to secure this employment can be grounds for rejection of my application or, if I am employed by Personal Caregiving Services, can be grounds for my immediate termination from Personal Caregiving Services.

I authorize Personal Caregiving Services to check and verify any and all information listed above, including but not limited to my references, record of employment, education record, and any other information I have provided.

Unless otherwise noted, I authorize the references listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure.</p>

I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

I understand that this application is not a contract, offer or promise of employment and that if hired, I will be an at-will employee. As such, I will be able to resign at any time for any reason.

Acknowledgement and Authorization

I agree to all the terms and conditions. *

I agree to all the terms and conditions.

Applicant Signature *

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