RELIANCE CARE SOLUTIONS

Employment Application

Reliance Care Solutions LLC is an equal opportunity employer. Applicants will be considered regardless of race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status. Equal access to the hiring process, services, and employment is available to all individuals.

Each question should be answered completely and accurately.

No action will be taken on this application until all questions have been answered and the application has been signed and dated. Verification of eligibility to work in the U.S. and a through criminal background check will be required if an employment offer is made.

Full Name*

First NameLast Name

Social Security Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Phone Number*

E-mail*

Confirmation Emailexample@example.com

Position(s) applying for*

We are urgently hiring for Direct Support Professionals available for 2nd shift and weekend positions!

Referral:

Desired Wage (Hourly)*

Do you have experience in the field of Developmental Disabilties?*

YESNO

Are you over the age of 18?*

YESNO

Are you eligible to work in the United States?*

YESNO

Are you currently employed?*

YESNO

Date available for work*

Date

Have you applied here before?*

YESNO

Are you related to any current employees or have any family members employed by RCS at this time? If yes, please specify the individual’s name and your relationship.

What are you available to work?*

Full timePart timeWeekends Only

What shift are you looking to work?*

First (7:00am-3:00pm)Second (3:00pm-11:00pm)Third (11:00pm-7:00am)Twelve (7:00am-7:00pm)

Are you a valid licensed driver with auto insurance?*

YESNOValid driver without insurance

Have you been convicted of a felony/misdemeanor (other than traffic violations)?*

YESNO

If so, provide the location, date and result/outcome for each conviction:*

EDUCATION

Highest level of education completed:*

Please complete the appropriate sections

	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

WORK HISTORY

Please list your two most recent employers, list the most recent first.

1. Employer

Employer's Name (Most current)*

Address & location of Employer*

Your title*

May we contact this employer?*

YESNO

Supervisor*

First and Last Name

Phone Number*

Start date*

MonthDayYear

End date

MonthDayYear

Wage:*

Role and Responsibilities:*

Reason for leaving*

2. Employer

Employer's Name (Second most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Start date

MonthDayYear

End date

MonthDayYear

Role and Responsibilities:

Reason for leaving:

ADDITIONAL INFORMATION

Do you have a valid driver's license?*

YESNO

Do you have auto insurance?*

YESNO

Do you have less than 6 points on your driving record?*

YESNO

Do you have a U.S. military service record?*

YESNO

If yes, branch of service*

Discharge date and rank*

Tell us about your caregiving work experience or other job-related accomplishments, projects, and awards.

List any additional information you would like us to consider:

REFERENCES

List three professional references, (business or work, not relatives) that you have known for at least one year. Please list at least one previous supervisor.

1. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

2. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

3. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

AUTHORIZATION

I understand that Reliance Care Solutions LLC is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed.

I authorize Reliance Care Solutions LLC to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to Parker Residential & Care Services. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original.

Pre-employment screening may be required (background checks, motor vehicle checks).Testing may be applicant or employer paid based on the employer.

I understand that this application is current for 30 days. At the conclusion of this time, if I have not heard from Reliance Care Solutions LLC and still wish to be considered for employment, it will be necessary to complete a new application.

I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself, or the employer Reliance Care Solutions LLC at any time, with or without cause or notice, for any reason or no reason.

By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree

You must agree to accept the terms of the document in order to submit an application.

Type signature*

Date*

Date

Please upload any training certication that you already have aquired:

First Aid/CPR, click Choose File

Annual/Initial DSP Training, click Choose File

CNA/HHA/STNA training certificates do not satisfy DODD requirements.