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.
Cell Phone Number
Please enter a valid phone number.
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*
Full-timePart-timePRN
Current Hourly Pay Rate (if employed)
Desired Pay Per Hour*
YesNo
YesNo
YesNo
If yes, when?
Reason for leaving (if previously employed)
YesNo
YesNo
If yes, please explain
YesNo
YesNo
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*

Powered by Jotform SignClear
Date of Signature*

MonthDayYear
Date
Should be Empty: