Provision Employment Application

2300 George Dieter, El Paso, TX 79936 Tel: (915)955-2525
Date

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Street
City
State
ZIP Postal Code
Email address
example@example.com
How did you hear about us?
Type of employment desired
Please Specify Days and Hours Available
Position applied for:

PRN/As neededPart-Time
Current hourly pay rate
Desired pay per hour
Are you legally eligible to work in the US?

YesNo
Are you available to work Call Outs, if needed?

YesNo
Have you ever been employed by our company?

YesNo
If yes, when?
Why did you leave?
Do you have any friends or family employed at this location?

YesNo
FYI: Conviction will not be a deciding factor in continuing the pre-screening process or potential employment opportunities
Have you been convicted of a crime in the last seven (7) years?

YesNo
If yes, please explain:
During the hiring process, do you agree to a criminal background check?

YesNo
During the hiring process, do you agree to provide a Motor Vehicle Record?

YesNoNA
Educational Background: Please Answer the Following Questions

List previous educational history:

	Educational History	Field of Study	Did you Graduate?
Institution
Institution
Institution

Document Checklist:

	Yes	No	Expires
CPR/First Aid
Driver's License
TB Screening

What do you think is the most difficult part of caregiving or customer service work?
Ms Jackson ask you to apply BENGAY muscle rub on her back what would you do?
In what situations do we provide services not listed in the SERVICE PLAN?
What is a DNR?
Why is it important to work within your caregiver scope or job description?
EMPLOYMENT BACKGROUND
List your previous employers beginning with the most recent employer.
Employer Name
Phone Number
Please enter a valid phone number.
Address
From
To
Job Title
Supervisor Name/Phone
Reason for leaving
May we call to verify?
What was your starting hourly rate?
What was your final hourly rate?
Responsibilities
Employer name
Phone Number
Please enter a valid phone number.
Address
From
To
Job Title
Supervisor Name/Phone
May we call to verify
What was your starting hourly rate?
What was your final hourly rate?
Responsibilities
Employer Name
Phone Number
Please enter a valid phone number.
Address
From
To
Job Title
Supervisor Name/Phone
May we call to verify
What was your starting hourly rate?
What was your final hourly rate?
Reason for leaving
Responsibilities
Employer Name
Phone Number
Please enter a valid phone number.
Address
From
To
Supervisor Name/Phone
Job Title
May we call to verify
What was your starting hourly rate?
What was your final hourly rate?
Reason for leaving
Responsibilities
References: List the name, relationship, number of years acquainted, and phone number of three references. No relatives please

References

	First, Last	Phone Number	Relationship	Years Aquianted
Name
Name
Name

**CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, national origin, ancestry, veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws.
Applicants Signature

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Date

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Date
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