Silver home care application to the closely following the

Caregiver Employment Application

EDUCATION
Highest Level of Education Completed *

GED High School Diploma Associates Degree Bachelors Degree or higher
Please select all that Apply:

I am a CNA I am a Nursing Student None of the Above
CNA Registration Number (If Applicable)

Personal References:

Two verifiable Personal References, not related to you are Required
Reference 1 *
Name of Reference
Relationship *
Years Acquainted *
Phone *
Email *
Reference 2 *
Name of Reference
Relationship *
Years Acquainted *
Phone *
Email *
Reference 3
Name of Reference
Relationship
Years Acquainted
Phone
Email
I authorize Silver Home Care to contact the References listed above. *

Yes No
Signature

Clear

Consent for Drug Testing
Successful completion of pre-employment drug testing is a requirement of employment with Silver Home Care. You have the right to refuse this testing but in doing so your application will will be denied. Drug testing will be administered following the completion of your interview if you have been offered a position. We will use an oral swab to collect your saliva to test for the presence of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines. If you are prescribed any medications that may produce a positive result, please notify us in advance of the test. If you believe the results of the test are not accurate, you have the right to request a retest of the original sample at a licensed laboratory of your choice within 3 days.
Full Name *

First Name Middle Name Last Name
I have read and understand the scope, method and policy stated above.

YES NO
I agree to submit to an Oral Swab test to screen for the use of Cocaine, Marijuana, Opiates, Amphetamines, Methamphetamine, and Benzodiazepines.

YES NO
I agree to submit to a drug and alcohol test in the event that I am involved in an accident or other incident where my actions/decisions or lack thereof are potentiallya contributing factor or if drug or alcohol use during work hours is suspected.

YES NO
Date

Month Day Year
Date
Signature

Clear

Tell us why you are interested in working for Silver Home Care
How did you hear about us?
Upload Cover Letter/Resume/References

If you have a cover letter, resume or written references you may upload them here, it is not required.
Cover Letter/Resume/References

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Employment Application