SouthCARE Application
Please complete the form below to apply for a position with us.
Applicant Information
Full Name
First Name
Middle Name
Last Name
Date of Application
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Month
-
Day
Year
Date
Birth Date
Please select a month
January
February
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Month
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1
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31
Day
Please select a year
2025
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Year
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
example@example.com
Phone Number
Available Start Date
-
Month
-
Day
Year
Date
Position Applied
Please Select
CARE Staff (in-Home)
Admin Staff
Have you ever worked for this company?
Please Select
Yes
No
Please specify
Have you ever been convicted of a felony?
Please Select
Yes
No
If yes, please explain
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Education
High School
Address
From:
To:
Did you graduate?
Yes
No
Diploma:
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College?
Address
To:
From:
Did you graduate?
Yes
No
Degree:
Other Education:
Please explain:
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Previous Employment
Must have at least two verifiable previous/current employments.
Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title:
Starting Salary:
Ending Salary:
Responsibilities
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
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Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title:
Starting Salary:
Ending Salary:
Responsibilities
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
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Company
Phone Number
Please enter a valid phone number.
Address
Supervisor
Job Title:
Starting Salary:
Ending Salary:
Responsibilities
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
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Personal References
Please list three family members, co-workers, friends, etc.
Name:
Phone Number:
Relationship:
Name:
Phone Number:
Relationship:
Name:
Phone Number:
Relationship:
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Military Service
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer & Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Applicant Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Supervisor Name
First Name
Last Name
Date (OFFICE USE ONLY)
-
Month
-
Day
Year
Date
Apply
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