Application of Employment
PERSONAL DATA
Application Date:
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-
Month
-
Day
Year
Date
Name:
*
First Name
Middle Name
Last Name
Suffix
Email:
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example@example.com
Phone Number:
*
Please enter a valid phone number.
Social Security Number:
*
Please enter a valid social security number
We may use SMS during the hiring process. Do you give us permission to text you?
*
Please Select
Yes
No
*I consent to receive text messages at the mobile number provided. Message and data rates may apply. Reply 'STOP' at any time if you no longer wish to receive text messages regarding this job
Date of Birth:
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Month
-
Day
Year
Date
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Applying For:
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Please Select
Assistant Location Manager
Community Liaison
Direct Support Professional
NMET Driver
Companion Aide
LPN/RN (PRN)
Intern
Desired Start Date:
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Month
-
Day
Year
Date
Employment Desired:
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Full Time
Part-Time
Morning Shift
Evening Shift
Night Shift
Weekends
PRN
Desired Wage Range:
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Are you First Aide and CPR Certified? If not, please obtain certification prior to start date.
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Yes
No
Do you have any other certifications or licenses? If so, please list below.
*
Do you have any healthcare experience with any of the following listed below? Please select all that applies.
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Elderly
Intellectual and Developmental Disabled Individuals
Mental Health
Veterans
Other
Are you a U.S Citizen?
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Yes
No
Are you authorized to work in the U.S.?
*
Yes
No
Are you a veteran?
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Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain:
How were you referred to us?
*
Online Job Board
Company Website
Friend or Family Member
Current Employee
Recruitment Office
Name of referral:
*
WORK & EDUCATION HISTORY
Upload Resume:
*
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Professional Reference 1
*
First & Last Name
Company
Relationship
Phone Number
Email
Professional Reference 2
*
First & Last Name
Company
Relationship
Phone Number
Email
ACKNOWLEDGMENT
Bright Path Care Services, LLC does not exclude employment to or otherwise discriminate against any person on the basis of race, color, sexual orientation, national origin, disability, or age. This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulation of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91. The information that I have given is true and accurate to the best of my knowledge.
Do you require any reasonable accommodations to perform the duties of position applied?
*
Yes
No
BACKGROUND CHECK & DRUG SCREENING NOTICE TO APPLICANT AUTHORIZATION
The purpose of this notice is to inform you that we will be conducting a pre-employment background investigation and drug screening in conjunction with your application for employment with our company. This background investigation may involve verifying or reviewing any of the following relevant information: Social Security Number, DMV Record Criminal Convictions, Prior Employment History Educational History. As part of this investigation, the Company will obtain a consumer report from a Consumer Reporting Agency, for employment purposes. The Company may use information in the consumer report for decisions related to your employment. A copy of the report will be provided to you, free of charge, if you wish. By your signature below, you authorize the Company to obtain this consumer report and drug test. If you wish to receive a copy of the results, please include your address below. This notice and authorization is in accordance with the Fair Credit Reporting Act.
Signature
*
Name:
First Name
*
Last Name
*
Date:
Street Address
Address Line 2
City
State
Zip
Date
*
Submit
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