Xclusive Care Services Application Form

APPLICATION FORM

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, medical condition, national origin, or marital status.

Personal Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you legally authorized to work in the United States*
Driver's License/ID Card*

Cancelof
D.L Expiration Date*

MonthDayYear
Date
SSN Upload*

Cancelof
CPR. Red Cross or American Heart ONLY thanks.*

Cancelof
CPR Expiration Date*

MonthDayYear
Date
Resume*

Cancelof
Cell Phone*
Home Phone
Email*
How did you hear about us?
Have you ever been convicted of a crime?*
If yes, explain the nature and dates of the conviction(s)
What do you like most about working with the elderly, disabled, or convalescing client?
What do you find most challenging in this type of work?

Emergency Contact Information.
Please help us protect you better by providing the HR Department with names and phone numbers of people to be contacted in case of an emergency. This information will be kept in your employee file and used only in an emergency.

To be effective, the people you provide should be individuals who can be reached during daytime hours (spouse, family members, friends, neighbors, etc.).
Name. 1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Phone Number*
Relationship*
Name. 2*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Relationship

Attributes
Please check the options whether you have assisted with or performed the following tasks
Additional Skills

Personal References. Give 2 names of persons not related to you whom you've known at least 1 year.
Reference 1*
Reference 2*

Certification

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that the withholding, misrepresentation or falsification of information shall be grounds to refuse employment, or, if employed, shall be grounds for dismissal.
Date*
Print Your Name*
Signature*

Powered by Jotform SignClear
Should be Empty:

APPLICATION FORM