Job Application

Job Application
In compliance with state law, The Adult Caring Place does NOT hire individuals who are less than 18 years of age.

Please complete the application, choosing to save your work and continue at a later time, if needed. For an optimal experience we encourage you to complete this application from a laptop or desktop.

To ensure an efficient hiring process we encourage you to check your email daily and respond promptly.

For questions or concerns contact us via phone at (317) 771-9608 or via email at HR@TheAdultCaringPlace.com
Date*

MonthDayYear
Date
Are you at least 18 years of age?

YesNo
Who referred you to The Adult Caring Place?*
If no one referred you, please select "N/A"
Please specify who referred you by providing their name, if available.
If you do not have their name, enter "N/A."
Full Name*

First NameLast NameSuffix
E-mail*
example@example.com
Phone Number*
In which city do you reside? *
What position are you applying for?*
Available start date:*

MonthDayYear
Date
Type of employment required*

Using the table below indicate your availability. *

	AM	PM	Nights	Other
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

If "other" was selected for any of the days in the table above please clarify.
Are you available to work overtime if required?*

YesNo
If currently employed, may we contact your current employer?*

YesNo
Hourly pay rate expectations*
Why are you applying for employment at The Adult Caring Place?*
Have you applied with us before?*

YesNo
Have you been employed with us before?*

YesNo
If yes, please provide previous employment dates.
Are you legally authorized to work in the United States?*

YesNo
Have you been convicted of a crime in the last seven (7) years?*

YesNo
If "yes", please explain.
A conviction will NOT necessarily be a disqualification for employment.
If considered for hiring, will you agree to provide a criminal background check?*

YesNo
The Adult Caring Place

(317)771-9608| HR@TheAdultCaringPlace.com| www.TheAdultCaringPlace.com

EDUCATIONAL BACKGROUND
Educational Information: (List the school's name, city/state, graduation status, and , degree/diplomas earned
What Nursing or relevant designations, licenses or registrations, if any, do you possess? (For VALID Indiana-based registrations/licenses list the type and registration dates.)

Do you have any of the following certifications?*

	Yes	No
CPR
First Aid
WHMIS

CPR - Last Certified Date

MonthDayYear
Date
First Aid - Last Certified Date

MonthDayYear
Date
WHMIS - Last Certified Date

MonthDayYear
Date
The Adult Caring Place

(317)771-9608| HR@TheAdultCaringPlace.com| www.TheAdultCaringPlace.com

EMPLOYMENT BACKGROUND
Provide the following information beginning with the most recent employer. (List the Employer's Name, Job Title, and date's of employement. *
May we contact the employers listed above?*

YesNoOther
Upload Resume

Cancelof
In the table below provide three (3) professional references*
By signing below, I certify that all the information I have provided is true, complete and correct. The information in this application or any attached cover letter or resume is not shared with any third parties.The information is used by the employer only as an aid in the hiring decision-making process. The applicant, by signing the application, gives the employer consent to collect the information contained herein and use for the purpose specified.

I authorize this company to investigate all statements contained in this application.

I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal. I understand that if I am hired, I will be required to provide a criminal background check at my cost, proof of identity and legal authority to work in United States, proof of certifications or educational qualifications, and a drivers abstract (if applicable).

Furthermore, I understand and agree that if employed, I am free to resign at any time, with a 1-week notice, without cause, and The Adult Caring Place reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitue an agreement or contract for employment.
Signature*

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Date*

MonthDayYear
Date
The Adult Caring Place

(317)771-9608| HR@TheAdultCaringPlace.com| www.TheAdultCaringPlace.com
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