FirstCare Employee Application

Employment Application
We are an Equal Opportunity Employer. We consider applicants for all positions without regard to color, creed, religion, sex, national origin, marital or veteran status, the presence of non-job related medical conditions or handicap, or any other legally protected status. It is our policy to abide by all Federal, State, and local laws concerning discrimination in employment. No question on this application is intended to elicit information in violation of any such law nor will any information obtained in response to any question be used in violation of any such law.
Date of Application

MonthDayYear
Personal Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Email*
example@example.com
How long at present address?*
Social Security #*
Position applying for*
Expected wages/salary*
Date available for work*

MonthDayYear
Employment referral source

WebsiteFirstCare EmployeeSocial MediaOther
Licensure #
State issued
Expiration date

MonthDayYear
Certificate #
State issued
Expiration date

MonthDayYear
Current CPR

YesNo
Expiration date

MonthDayYear

Education & Training
Education History*
Please list any other training, education, special skills, or certificates/licenses that you possess:

Work History
Please list present and former employers beginning with the most recent:
Name & Address of Company
Name of Supervisor
Last Salary
Describe Experience
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving
May we contact?

YesNo
Name & Address of Company
Name of Supervisor
Last Salary
Describe Experience
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving
May we contact?

YesNo
Name & Address of Company
Name of Supervisor
Last Salary
Describe Experience
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving
May we contact?

YesNo
Have you ever been convicted of a felony or misdemeanor? *

YesNo
Authorization:
“I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, if employed, falsified statement on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein (including reference and credit checks) and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from liability for any damage that may result from utilization of such information. If employed, I understand and agree that such employment may be terminated at any time without prior notice and that my employment will not be governed by any expressed or implied contract but is at will.
Applicant's Signature*

Clear
Should be Empty:

Employment Application

Personal Information

Education & Training

Work History