JOB APPLICATION
Greater Living Home Care is currently hiring RN's, LPN's, CNA's, and PCA's. To apply, please complete this application in its entirety.
Name
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First Name
Last Name
What is your Date of Birth?
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What is your Social Security Number?
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
Please enter a GMAIL EMAIL address. This will be needed to share important documents in Google Drive in the future.
Position Applying For
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RN
LPN
CNA
PCA
Administrative Position
Other
Hourly Pay Expectation
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How many years of experience do you have in the selected position?
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How did you hear about this position?
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Indeed.com
Facebook
Instagram
Flyer
Client Referral
Staff Referral
If someone referred you for this position, please enter his or her name below.
Are you a U.S. Citizen or approved to work in the United States?
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YES
NO
Do you have CPR certification that is less than 2 years old?
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YES
NO
Do you have First Aid certification that is less than 2 years old?
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YES
NO
Do you have NEGATIVE TB test results that are less than 1 year old old?
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YES
NO
Do you have a CNA or PCA certification?
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YES
NO
Not Applicable
Do you have an RN License?
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YES
NO
Not Applicable
Do you have an LPN License?
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YES
NO
Not Applicable
Have you ever been convicted of a misdemeanor?
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YES
NO
If yes, please list your charge(s) and the date(s) of occurrence.
Have you ever been convicted of a felony?
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YES
NO
If yes, please list your charge(s) and the date(s) of occurrence.
What are your days and hours of availability?
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What mode of transportation do you have?
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I have my own car.
I rely on public transportation such as UBER or buses to get to work.
I have a friend or family member who can take me to and from work.
How many miles from your home are you willing to travel for work?
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Have you ever applied to or worked for Greater Living Home Care before?
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YES
NO
Do you have any friends, relatives, or acquaintances working for Greater Living Home Care?
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YES
NO
If yes, state name and relationship
EDUCATION AND TRAINING
Please list any education or training you have below.
High School Name
*
High School City and State
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High School Year Graduated
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#1 College/University Name
#1 College/University City and State
#1 College/University Years Attended
#1 College/University Degree Earned
#2 College/University Name
#2 College/University City and State
#2 College/University Years Attended
#2 College/University Degree Earned
Vocational School/ Specialized Training Name
Vocational School/ Specialized Training City and State
Vocational School/ Specialized Training Year Graduated
Vocational School/ Specialized Training Degree or Certificate Earned
Please list any other specialized training or skills you possess that you would like for us to know about below. (Ex: CPR, First Aid, BLS)
*
WORK HISTORY
Please list your 3 most recent and relevant employers for the position you are applying for below. Please be sure to show a minimum of 5 most recent years of work experience.
Previous Employers
Employer #1 Name:
*
Job Title:
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Supervisor Name:
*
Employer Telephone:
*
Please enter a valid phone number.
Employer Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Employed:
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Enter the start and end dates. (Example: May 2021- August 2024)
Reason for Leaving:
*
Employer #2 Name:
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Job Title:
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Supervisor Name:
*
Employer Telephone:
*
Please enter a valid phone number.
Employer Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Employed:
*
Enter the start and end dates. (Example: May 2021- August 2024)
Reason for Leaving:
*
Employer #3 Name:
Job Title:
Supervisor Name:
Employer Telephone:
Please enter a valid phone number.
Employer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Employed:
Enter the start and end dates. (Example: May 2021- August 2024)
Reason for Leaving:
REFERENCES
Please provide 3 PROFESSIONAL references and 1 PERSONAL reference below.
PROFESSIONAL REFERENCE #1 Name:
*
First Name
Last Name
PROFESSIONAL REFERENCE #1 Phone:
*
Please enter a valid phone number.
PROFESSIONAL REFERENCE #2 Name:
*
First Name
Last Name
PROFESSIONAL REFERENCE #2 Phone:
*
Please enter a valid phone number.
PROFESSIONAL REFERENCE #3 Name:
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First Name
Last Name
PROFESSIONAL REFERENCE #3 Phone:
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Please enter a valid phone number.
PERSONAL REFERENCE #1 Name:
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First Name
Last Name
PERSONAL REFERENCE #1 Phone:
*
Please enter a valid phone number.
EMERGENCY CONTACT
Emergency Contact Person Fill Name
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First Name
Last Name
Relationship to Emergency Contact Person
*
Spouse
Sibling
Parent
Grandparent
Emergency Contact Person's Phone Number
*
Please enter a valid phone number.
Emergency Contact Person's Email Address
*
example@example.com
DIRECT DEPOSIT INFORMATION
Bank Name
Routing Number
Account Number
Voided Check (You may upload a voided check instead of entering the information above.)
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Resume
*
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Front of Driver's License
*
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Back of Driver's License
*
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Front of Social Security Card
*
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RN,LPN, PCA, CNA License, Certifications
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TB Test Results
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CPR/First Aid
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Selfie (Please upload a picture of yourself.)
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File Upload
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TB Test Results
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AT-WILL
The relationship between you and Greater Living Home Care is referred to as "at will." This means that you can be terminated at any time for any reason, with or without cause, with or without notice, by you or Greater Living Home Care. No representative of Greater Living Home Care has authority to enter into any agreement contrary to the foregoing "at will" relationship. You understand that your relationship is "at will," and that you acknowledge that no oral or written statements or representations regarding your position can alter your at-will employment status, except for a written statement signed by you and either our CEO. Greater Living Home Care is an equal opportunity company.
Signature:
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Date
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Month
-
Day
Year
Date
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