Employment Application

Employment Application

Home Care - Skilled and Non-Skilled
Date Available to Work*
Position (Job Class) Applying for:*

Registered NurseLicensed Practical NurseHome Health AideAdministrationPhysical Therapist/Occupational TherapistOther
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address*
Phone Number*
Please enter a valid phone number.
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date of Birth
Social Sec #*
Gender*
Language Skills. Provide languages other than English (Spanish, French, Other)?

Additional Information
Have you ever been investigated for abuse, neglect or domestic violence?*

YesNo
Have you ever been convicted of a felony or misdemeanor crime?*

YesNo
Are you legally authorized to work in the U.S.? (as an employee of Faithful Caregivers LLC, you will be required to provide the documentation proving your eligibility to work in the U.S.)*

YesNo
References
Personal Reference Name

First NameLast Name
Personal Reference Phone Number
Please enter a valid phone number.
Personal Reference Email
example@example.com
Employer Reference Name

First NameLast Name
Employer Reference Phone Number
Please enter a valid phone number.
Employer Reference Email
example@example.com
Employer Reference Name

First NameLast Name
Employer Reference Phone Number
Please enter a valid phone number.
Employer Reference Email
example@example.com
NOTICE/AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES/INVESTIGATIVE CONSUMER REPORT

In connection with my application for employment with Faithful Caregivers LLC. I authorize the the agency or its agents to procure a consumer report and/or investigative consumer report about my background, character or reputation, including, but not limited to, information as to my employment, education, consumer credit history (consumer credit history will only be verified if appropriate for certain job descriptions), driving record, social security number verification, criminal record and/or other public records history. I authorize all persons to fully disclose information relevant to this investigation. I release from liability all persons, companies and governmental or other agencies disclosing such information. I further authorize that a photocopy of this authorization may be considered as an original.

I HAVE READ, UNDERSTAND AND AUTHORIZE, ANY PERSON, AGENCY OR OTHER ENTITY CONTACTED BY THE AGENCY OR ITS AGENCY TO FURNISH THE

ABOVE-MENTIONED INFORMATION.

Name:  First Name*   Last Name*   Signature*
Other Alias Names:   First Name*   Last Name*

Faithful Caregivers LLC is an Equal Employment Opportunity
Application Certification
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Faithful Caregivers LLC and I hereby release and discharge any of the above and Faithful Caregivers LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check

I (your name) NAME LISTED ON APPLICATION hereby authorize Faithful Caregivers LLC to request and receive from all prior employers within one year of the date of this application, and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.
I acknowledge the above
Signature*

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Employment Application

License/Certification (copies of licenses/certifications will be required for employment file)

Education and Employment

Work Experience

Employment Information

Transportation

Additional Information

References

Application Certification