Staff Intake Form

Staff Intake Form
Applicant Full Name
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
CNA/GNA License Number
License Expiration Date

MonthDayYear
Date
CPR Certification Status
Upload CNA/GNA License (front/back)

Cancelof
Upload CPR Card (if available)

Cancelof
Upload ID or Work Eligibility Document

Cancelof
Upload Resume (PDF or WORD)

Cancelof
Experience & Skills (select all that apply)
If Other or Special Skills, describe here:
Which days are you available to work? (select all that apply)
Shift preference (select all that apply)
Available working hours (ex: 7a-3p)
How many miles are you willing to travel? (ex: 10 miles, 20 miles, no limit)
When are you able to start working

MonthDayYear
Date
How many years of experience do you have?
I understand the pay rate is $18/hr and hours are client specific and no guaranteed shifts.
Type full legal name to sign and certify information is true to the best of my knowledge.
Date signed

MonthDayYear
Date
“Applicants may be contacted by email first to confirm position alignment before any phone interview is scheduled.”
Employment is contingent upon a satisfactory background check.
Should be Empty: