Job Application
Please complete the form below to apply for a position with us.
Personal Information
Full Name
*
First Name
Middle Initial
Last Name
Which position are you applying for?
*
Caregiver
Other
Your Address
*
Street Address
Street Address Line 2
City
State (ex. WY)
Zip Code
Phone number 1
*
Please specify whether this is a Cell or Home number:
Email Address
*
Are you a US Citizen?
*
Yes
No
Social Security/Visa #
*
Are you authorized to work in the U.S.?
*
I am authorized to work in the U.S. for any employer.
I am authorized to work in the U.S. only for my current employer.
I require sponsorship to work in the U.S.
I do not know my work status.
Do you have reliable transportation?
*
Yes
No
Please list any previous names or aliases or print none:
*
What is your date of birth?
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-
Month
-
Day
Year
Date
What is your county of residence?
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What states have you lived in for the last 5 years?
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Do you have any work restrictions?
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Yes
No
If yes, what are they?
Emergency Contact
Name
*
First and Last Name
Relationship
*
Phone Number
*
Employment Info
Date Available to start work:
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-
Month
-
Day
Year
Date Picker Icon
Please share your Availability (please be as specific as possible):
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Time Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Desired Employment Level
Full Time
Part Time
On Call
Live-In
Overnight
Are you available to work overnights? If yes, please include dates and times above.
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Yes
No
Are you available in an Emergency?
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Yes
No
Are you willing to be on call?
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Yes
No
How did you hear about the position?
*
Person (Name person)
Ad (Give date and source)
Other (Describe)
Referrer Description
Criminal History
A conviction will not necessarily disqualify an applicant from employment. Proximity in time, severity and pertinence of the conviction to the job will be considered.
Have you ever been convicted of a felony or misdemeanor?
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Yes
No
If yes, what year and please explain
Experience
Discuss any training or experience you have had with the elderly?
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Are you certified with documentation as a PCA/STNA?
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Yes
No
Do you have any allergies?
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Yes
No
If yes please list them:
Can you go to a clients home that has cats?
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Yes
No
Can you go to a clients home that has dogs?
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Yes
No
Education
School 1
School Name
Location
Attended Start
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Month
-
Day
Year
Date
Attended End
-
Month
-
Day
Year
Date
Did you graduate?
Yes
No
Major / Topic of Study
Degree
Location
Attended Start
-
Month
-
Day
Year
Date
Attended End
-
Month
-
Day
Year
Date
Did you graduate?
Yes
No
Major / Topic of Study
Degree
School 2
School Name
Location
Attended Start
-
Month
-
Day
Year
Date
Attended End
-
Month
-
Day
Year
Date
Did you graduate?
Yes
No
Major / Topic of Study
Degree
School 3
School Name
Location
Attended Start
-
Month
-
Day
Year
Date
Attended End
-
Month
-
Day
Year
Date
Did you graduate?
Yes
No
Major / Topic of Study
Degree
Work History
Employer 1
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Start Date
*
-
Month
-
Day
Year
Date
Employment End Date
*
-
Month
-
Day
Year
Date
Supervisor Name
*
Supervisor Number
*
Reason For Leaving
May we contact?
*
Yes
No
Employer 2
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Start Date
-
Month
-
Day
Year
Date
Employment End Date
-
Month
-
Day
Year
Date
Supervisor Name
Supervisor Number
Reason For Leaving
May we contact?
Yes
No
Employer 3
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Start Date
-
Month
-
Day
Year
Date
Employment End Date
-
Month
-
Day
Year
Date
Supervisor Name
Supervisor Number
Reason For Leaving
May we contact?
Yes
No
References
Number of References
1
2
3
Reference 1
Name
*
Relationship
*
Occupation
Reference Phone Number
*
Reference 2
Name
*
Relationship
*
Occupation
Reference Phone Number
*
Reference 3
Name
*
Relationship
*
Occupation
Reference Phone Number
*
Authorization to Release Information
Certification and Release: I certify the above stated and indicated are true in fact and no misrepresentation of me has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or discharge at any time during employment. I authorize Silver Crown Services to verify any and all information contained within this application, but not limited to, criminal history, employment references, and motor vehicle driving records. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & 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 and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment. Restrictive Covenant: I agree not to do business directly with any individual or business entity that Silver Crown Services has introduced to me or by entering into employment with such individuals or businesses. You Acknowledge That You Are Being Hired As A PRN Employee. Definition Of A PRN Employee: As The Situation Demands, When Necessary Or As Needed.
By selecting “I Agree” below, you agree to the above conditions of employment.
*
I Agree
I do NOT Agree
Disclaimer and Signature
By signing your name electronically on this application, you are agreeing that your electronic signature is the legal equivalent of your physical signature.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Is Job Application
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Agency
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