CORE CARE AGENCY

CORE CARE AGENCY
EMPLOYMENT APPLICATION
Please complete the entire application
1. Employer Information

Employer: Core Care Agency

Address: 3143 S 840 E Saint George, Utah 84790

Telephone: 435-673-3585
It is the policy of Core Care Agency to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national, age, disability or veteran status.
Applicant Full Name
Address

Home Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
Numbers of years at this address
Daytime phone
Evening Phone
Mobile phone
Social Security Number
Driver's License (State/Number)
Who should be contacted if you are involved in an emergency?
Contact Name
Relationship to you
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Daytime phone
Evening phone
Job Position Applied For
Full or Part Time?
5. Salary Desired
per
6. Which of the companies/departments are you applying

Bright Morning StarAll Star Kids TransportationNanny Agency/other -AgencyBee Wow Hair SalonBreathe Care InternationalType option 6
Which of the companies/departments are you applying
Breathe Care International
MP Cuisine

Core Care Consulting
7. Have you applied to Core Care Agency Previously?

YesType option 2
If yes, when?
8. Who referred to Core Care Agency?
9. Do you have Friends and relatives who work at Core Care Agency?
Yes
No
If yes, when
10. Are you at least 18 years of Age?
11. How will you get to work?
12. Are you willing to work any shift, including nights and weekends?

YesNo If no, please state Limitations:
No If no, please state Limitations:
If no, please state Limitations
13. If applicable, are you available to work overtime?

YesNo
14. If you are offered employment, when will you be available to begin work?
15. If hired, are you able to submit proof that you are legally eligible for

employment in the United States?
Yes
No
16. Applicant's Skills

List any skills that maybe useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each skill. (One represents poor ability, while five represents exceptional ability
Skill
Years Of Experience
Type a question

12345
Skill
Years Of Experience
Type a question

12345
Skill
Years Of Experience
Type a question

12345
17. Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is need continue on the back page of this application.
Employer Name
Supervisor Name
Address
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)

MonthDayYear
Date
Employer Name
Supervisor Name
Address
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)

MonthDayYear
Date
Employer Name
Supervisor Name
Address
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)

MonthDayYear
Date
Employer Name
Supervisor Name
Address
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)

MonthDayYear
Date
18. Applicant's Education and Training
College/University Name and Address
Did you receive a degree?

YesNo. If yes, type and date received.
College/University Name and Address
Yes
Yes

No. If yes, type and date received.
High School/GED Name and Address
Did you receive a degree?

YesNo. If yes, type and date received.
Other Training/Graduate/technical/Vocationa Name and Address
Did you receive a degree?

YesNo. If yes, type and date received.
Please indicate current professional licenses or certifications that you hold
Awards/Honors/Special achievements
List any three non-relatives who would be willing to provide a reference for
Name
Address

Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
Telephone
Relationship
Name
Address

Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
Telephone
Relationship
Name
Address

Address

Street Address Line 2

City/State/ZIPState / Province

Postal / Zip Code
Telephone
Relationship
20. Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:
The information contained in this application is correct to the best of my knowledge. I hereby authorize Core Care Agency and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and /or Volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation or public (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Core Care Agency or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data
Signature

Clear
Date

MonthDayYear
Date
Core Care Agency and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers and dates of birth.
Should be Empty:

CORE CARE AGENCY

EMPLOYMENT APPLICATION