EMPLOYMENT APPLICATION
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mark all that apply: Preferred days:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What type of employment do you prefer?
Live-in: make the care home my permanent residence or majority residence
Live-off: work my shift and leave
Dayshift
Grave - work through the night
Flexible (I am open to discussing the different options)
Other: add comments below.
Explain the type of employment you most prefer in your own words. It does no one any good if you say you can do any just to get the job, but you actually cannot stay awake for a night shift, for example.
Check all that you have:
Negative TB Test
Physical
CPR/FirstAid Card
Would you pass FBI Fingerprint Background check
Negative Covid-19 Test
Do you have other Training Certificates
Check all that you are good at:
Cooking
Cleaning
Incontinence Care
Organizing
Activities for Seniors
Documenting Incidents
Select all the areas of town that you could feasibly work at:
Henderson
Summerlin
North Las Vegas
East Las Vegas
Southwest Las Vegas
Northwest Las Vegas
West Las Vegas
Date Available
-
Month
-
Day
Year
Date
Previous Employment 1
Company
Job Title
Previous Employer 1 Phone Number
Please enter a valid phone number.
Previous Employment 2
Company
Job Title
Previous Employer 2 Phone Number
Please enter a valid phone number.
Previous Employment 3
Company
Job Title
Previous Employer 3 Phone Number
Please enter a valid phone number.
Please list any relevant skills, special interests, trainings
Reference 1
*
Name
Relationship
Reference 1 Phone Number
*
Please enter a valid phone number.
Reference 2
*
Name
Relationship
Reference 2 Phone Number
*
Please enter a valid phone number.
Reference 3
*
Name
Relationship
Reference 3 Phone Number
*
Please enter a valid phone number.
Please check all statements to indicate that you understand.
*
Employees may not accept money or gifts from our residents
Employees may not have guests while on shift, unless pre-approved
Employees are employed at will. Either party may terminate agreement for any time with or without cause.
If hired, I understand due to the nature of the business, (taking care of dependent people) I will have dependent people, and my co-workers relying on me to come to work when scheduled and on time, unless I am prevented to do so because of illness or emergency. In the event I am not able to come to work, I will immediately call in to work, so that proper staff coverage can be arranged. I further understand, that although this employment relationship is At-Will that I am not allowed to walk off my job and leave the residents unsupervised at any time. All non-emergency coverage must be handled between staff.
I understand that due to the nature of the business, (taking care of dependent people) I must always have the physical and mental ability to do the job. If I am disabled, or become disabled, I understand that I can request the company to make reasonable accommodations to assist me, however, the company may refuse if it compromises resident care, or causes an undue hardship on the company.
I understand that in order to work in this type of business I must have a “clean” criminal record, with no felonies or serious misdemeanor convictions. If hired, I understand that I will have to submit my fingerprints so that an extensive criminal record and background check can be conducted. If I am hired, I understand that if I get arrested for any reason, the facility may be notified by the licensing agency to immediately suspend me, and my employment may be terminated based on the outcome of the arrest.
I understand that prior to my acceptance of employment, and if hired, during my employment, I may be tested for the use of illegal drugs, and if found positive for use, my relationship with this company will be immediately terminated. I further understand that if hired, and I am found under the influence of drugs or alcohol while at work I will be immediately terminated.
I understand this company does not discriminate against applicants because of race, creed, color, religion, gender, or sexual preference, and that hiring is based on qualifications, personal characteristics, background check, and interview.
I hereby give my permission for this company to contact the pervious employers, schools and other contacts I have listed here and hereby release this company, and listed contacts from any liability arising from such communication of information. I understand that any falsification of this information is just cause to refuse hiring, and falsifications discovered later, if hired, will be grounds for immediate termination.
Applicant Signature
*
Date
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