HAPPY Caregiving, LLC. Employment Application

Employment Application

This application must be fully completed to be considered for employment. Information provided will be kept confidential. Please print clearly.
Position Applied For:
Personal Information
Name

First NameLast Name
Other Names Used
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security Number (Used For Background Checks)
Date of Birth
Eligibility
Authorized to work in the U.S.?
Previously employed by HAPPY Caregiving LLC?
If yes, when?
Valid Driver’s License?
State & License #
Excluded from Medicare/Medicaid programs?
Education & Training
High School
Year Graduated
Type:
College/University
Degree & Year
Other Training/Certifications (CNA, PCA, RN, CPR, First Aid, etc.):
License/Certification Numbers (if applicable):
Employment History (Most Recent First)
Employer #1
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name/Title
Position Title
Dates Employed
Duties Performed
Reason For Leaving
Employer #2
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name/Title
Position Title
Dates Employed
Duties Performed
Reason For Leaving
Employer #3
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name/Title
Position Title
Dates Employed
Duties Performed
Reason For Leaving
Professional References (No relatives)
Reference #1: Full Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Years Known
Reference #2: Full Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Years Known
Reference #3: Full Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Years Known
Background Information
Ever convicted of a felony?
(If yes, explain)
Convicted of abuse, neglect, or exploitation?
(If yes, explain)
In last 5 years, lived outside Arkansas?
(If yes, list states)
Consent to state & federal criminal background check?
Consent to TB screening & drug testing?
Certification & Signature

I certify the information in this application is true and complete. I understand that falsestatements may result in rejection or termination.
Signature
Date

MonthDayYear
Date

Employment Application

Personal Information

Eligibility

Education & Training

Employment History (Most Recent First)

Professional References (No relatives)

Background Information

Certification & Signature

Criminal Background Check Consent & Release