MEB LIFE HOME CARE Employment Application

First Name*

Middle Name

Last Name*

Street Address

Street Address Line Two

City*

State*

Zip Code*

Phone Number*

E-mail*

example@example.com

Birth Date

Date

SSN#*

Gender

Emergency Contact

First NameLast Name

Emergency Contact Number

Please enter a valid phone number.

I meet the following requirements (check all that apply):*

Certified Nursing Assistant

Current TB Skin Test or PPD?

YesNo_____________ Date received:

Do you have dependable transportation?*

YesNo

Current Auto Insurance?

Do You Have A Valid Drivers License or Identification?*

YesNo

How did you hear about MEB Life Home Care Agency?*

Date You Can Start*

MonthDayYear

Salary Desired*

Position Interested In (check all that apply):*

Full TimePart TimeTemporaryOn Call

Can you be called at the last minute in case of an emergency:*

YesNo

Times you are available to work:

I am applying for a position as a

PCACompanion/SitterNursing

Have you ever been investigated for abuse, neglect or domestic violence? If "yes", explain:

YesNo________________________________________________________________________________________________________________________________________________________________________________________________________

Have you been convicted of a crime in the last ten (10) years? If yes, please explain:

YesNo________________________________________________________________________________________________________________________________________________________________________________________________________

Introduce yourself to a prospective employer by sharing a personal letter about your experience. Include qualities that make you an outstanding employee and why you've chosen this profession: *

Important Note: This is much more than a job to us at MEB Life Home Care Agency. We are looking for employees that understand the significance of being welcomed into our agency. Additionally, we highly value professional letters written with attention to detail (grammar, punctuation, etc.).

List three words that describe your personality:*

What skills and experience do you have that are useful for caregiving? Feel free to be as in depth as possible.*

CPR/First Aid Certified?*

CPR/First Aid Expiration Date

Date

List any additional health & safety trainings:*

Anything else you would like to share:*

Highest Level of Education:*

High School

Name of High School Attended

Graduated High School?*

College*

Name of College/University Attended

Graduated College?*

College Area of Study/Degree*

Graduate School*

Name of Graduate School Attended

Graduated Grad School?*

Number of Years Attended Graduate School*

Area of Study/Degree*

List of other professional training:*

i.e. STARS, NCS, Doula training, conference workshops, etc.

Discuss any training or experience working with the elderly and disabled:*

i.e. STARS, NCS, Doula training, conference workshops, etc.

What do you like most about working with the elderly:*

i.e. STARS, NCS, Doula training, conference workshops, etc.

What do you like least about working with the elderly:*

i.e. STARS, NCS, Doula training, conference workshops, etc.

Please indicate whether you have assisted with or performed the following tasks for seniors:*

Current Employer Name*

i.e. Name of Family

Current Employer Position*

Your job title

Current Employer Salary*

Current Employer Start Date*

MonthDayYear

Current Employer Location*

i.e. Neighborhood

Current Employer Duties*

Please include an in-depth job description

Current Employer May We Contact?*

YesNo

Please explain why we may not contact your current employer:*

Previous Employment

Previous Employer*

i.e. Name of Family

Previous Employer Position*

Your job title

Previous Employer Salary

Previous Employer Start Date

MonthDayYear

Previous Employer End Date

MonthDayYear

Previous Employer Location*

i.e. Neighborhood

Previous Employer Duties*

Please include an in-depth job description

Previous Employer Reason for Leaving?*

Previous Employer May We Contact?*

YesNo

Please explain why we may not contact your previous employer:*

Third Recent Employer*

i.e. Name of Family

Third Recent Employer Position*

Your job title

Third Recent Employer Salary*

Third Recent Employer Start Date*

MonthDayYear

Third Recent Employer End Date*

MonthDayYear

Third Recent Employer Location*

i.e. Neighborhood

Third Recent Employer Duties*

Please include an in-depth job description

Third Recent Employer Reason for Leaving?*

Third Recent Employer May We Contact?*

YesNo

Please explain why we may not contact your third recent employer:*

May we contact your references?*

YesNo

Reference One Name*

Name of Reference

Reference One Relationship*

Reference One Phone*

Reference One Years Acquainted*

Reference Two Name*

Name of Reference

Reference Two Relationship*

Reference Two Years Acquainted*

Reference Two Phone*

Reference Three Name*

Name of Reference

Reference Three Relationship*

Reference Three Years Acquainted*

Reference Three Phone*

Please Upload Your Resume

Acknowledgement*

I have uploaded my resume. Without a resume, I understand that my application may not be considered.

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment

Signature

Date

Employment Application

Employment Desired:

Skills/Qualifications:

Education:

Mandatory Job History

References:

Resume: