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.
- 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
  Format: (000) 000-0000.
- Home Phone
  Format: (000) 000-0000.
- 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?
- 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
  Format: (000) 000-0000.
- Alternate Phone Number
  Format: (000) 000-0000.
- 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.Format: (000) 000-0000.
- Relationship

- Do you have a car?
- If you don’t have a car how would you get to work?
- Available to Start Date
  
  MonthDayYear
  
  Hour MinutesAM/PM Option
- How many hours can you work weekly?
- Are you available to work at nights?
- Are you available to work during weekends?
- Employment Desired
- Would you consider live-in?
- Are there any times you are not available to work?

- High School
- Diploma/GED
  
  Cancelof
- College
- Professional School
- License/Certificate
  
  Cancelof
- Please input License Number and Expiration Date
- Current TB
  
  Cancelof
- Please check the options whether you have assisted with or performed the following tasks
- Additional Skills

- Company
- Start Date
- End Date
- Job Title
- Reason Left
- Duties
- Supervisor
- Phone Number
- Company
- Start Date
- End Date
- Job Title
- Reason Left
- Duties
- Supervisor
- Phone Number
- Is it ok to contact your previous supervisor
- Company
- Start Date
- End Date
- Job Title
- Reason Left
- Duties
- Supervisor
- Phone Number
- Reference 1
- Reference 2
- 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
Should be Empty:

APPLICATION FORM

Certification