Caregiver Job Application Flourish Supportive Living

AN EQUAL OPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUALIFICATIONS
All applicants must: 1) be 18 years of age or older, 2) have a negative tuberculosis test, 3) undergo a criminal background check, and 4) have patience and compassion for the elderly population.

In addition to the above, applicants for caregiver positions must also: 1) successfully complete a medication administration class (QMAP) approved by the State of Colorado, 2) complete a Colorado State approved first aid course, and 3) complete the additional questionnaire attached to this application.

PLEASE NOTE: THIS IS NOT AN EMPLOYMENT CONTRACT. ALL employment opportunities with New Day Cottages Inc. are “at-will” which means that you are not guaranteed any length of employment. If hired, either you or New Day Cottages Inc. my terminate the employment relationship at any time, for any reason or no reason, and with or without prior notice.
Todays Date

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Have you lived in Colorado for the past 3 years?*

YesNo
If not please list all out of state addresses for the past 3 years

Sign Application:
I certify that all information provided by me to the questions and statements contained in this application and other pre-employment forms are true and correct without consequential omissions of any kind whatsoever. I understand that falsification, omission or misstatements are grounds for refusal to hire or, if hired, dismissal.

I further understand that I may be required to pass a medical examination (including a negative TB test) in order to qualify for employment, and I hereby authorize such medical examination.
Signature

Clear

Criminal Background and History Investigation Waiver

In accordance with Chapter VII for Residential Care Facilities in Colorado, any staff employee who has direct personal contact with residents of a facility shall be of good moral and responsible character.

In making such determination, New Day Cottages Inc. may have access to and shall obtain any criminal history record information from a criminal agency, subject to restrictions imposed by such agency, and verify social security number and birth date for any person responsible for the care and welfare of residents in Flourish’s homes.
Social Security Number (Please provide us a copy)*
Driver's License State*
Driver's License Number (Please provide us a copy of a photo ID)*
Birth Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Other Names Used
Prior Addresses in Last five Years*
List other states and counties of prior employment*
By affixing my signature below, I grant permission to New Day Cottages Inc. to conduct an investigation into my background, confirm my social security identification and birth date, and call my references and former employers for purposes of this application.
Signature

Clear
Current Date

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Date
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