Employment Application – Prestige Loving Home Care

Employment Application – Prestige Loving Home Care

Please complete this application in full to be considered for employment with Prestige Loving Home Care. All information is confidential and required for application review.
Application Date

MonthDayYear
Date
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-Mail Address
example@example.com
How did you hear about us?
Please specify days and hours you are available to work
Position Applied For
Employment Type
Current Hourly Pay Rate (if employed)
Desired Pay Per Hour
Are you legally eligible to work in the United States?
Are you available to work Call Outs, if needed?
Have you ever been employed at Prestige Loving Home Care?
If yes, when?
Reason for leaving (if previously employed)
Do you have any friends or family employed at this location?
Have you been convicted of a crime in the last seven (7) years?
If yes, please explain
Do you agree to provide a criminal background check during the hiring process?
Do you agree to provide a Motor Vehicle Record during the hiring process?
Educational Background – List up to three previous educational institutions

Document Checklist – Please indicate if you possess the following, and provide current and expiration dates as applicable.

What do you think is the most difficult part of caregiving or customer service work?
Ms. Jackson asks you to apply BENGAY muscle rub on her back. What would you do?
In what situations do we provide services not listed in the service plan?
What is DNR?
Why is it important to work within your CNA/PCA scope or job description?
Employment History – List your previous employers (up to 4, starting with the most recent)
Address
Dates Employed (From)
Dates Employed (To)
Responsibilities
Reason for leaving
May we call to verify?
References – Please list three references (no relatives): Name, Relationship, Years Acquainted, Phone Number
Applicant’s Signature
Date of Signature

MonthDayYear
Date
Should be Empty: