Calico Home Care Application for Employment
Name
*
First Name
Middle Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Position Applying for:
*
Please Select
Caregiver
CNA
RN
Administrative
If Applicable, Please Provide License Number and State where it was issued:
Date Available to Work:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you learn about Calico?
*
Social Media Ad
Friend/Relative
Website
Other
Are you currently employed?
*
Yes
No
Current Employer Name/Phone Number
May we contact your present employer?
*
Yes
No
Are there any duties on the job description that you cannot perform at this time?
*
Yes
No
If yes, please list below:
High School Graduate?
*
Yes
No
GED
List Schools, Colleges, Universities Attended:
*
Rows
Name and Location
Degree
Area of Study
School
School
School
School
Beginning with your present or most recent job, please complete the following information for all of your previous jobs. Include any job-related military service assignments and volunteer activities. Emphasize any jobs that you believe had relevant experience for the position for which you are applying.
*
Rows
Company Name
Job Title
Supervisor
City/State
Phone
Dates Employed
Reason for Leaving
Employer
Employer
Employer
Employer
Employer
Employer
Employer
List here any other information you would like us to know about you that would be relevant to the job you're applying for. Do not include organizations that indicate race, religion, gender, national origin, disability or other protected status.
References: List three individuals who are not related to you and are not previous employers.
*
Rows
Name
Phone
Relationship
Occupation
Reference 1
Reference 2
Reference 3
I certify that the information provided on this application and on any resume’ or any other documents submitted in conjunction with this application are true to the best of my knowledge. I authorize investigation of all statements contained in this application and all associated documents. This application and all associated documents shall be maintained on file for 1 year. I understand that neither this document nor any offer of employment from the employer constitutes an employment contract unless the employer and employee in writing execute a specific document to that effect. In the event of employment, I understand that false or misleading information given in my application and all associated documents or interview(s) may result in discharge. We consider applicants for all positions without regard to Race, Color, Religion, Sex, Sexual Orientation, National Origin, Age, Marital or Veteran Status, presence of Non-Job Related Medical Conditions or Disabilities, or any other legally protected status.
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
NOTE: INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. EMPLOYMENT DATA RECORD
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