CareAssist Application Form

EMPLOYMENT APPLICATION

CareAssist, LLC is An Equal Opportunity Employer
Personal Information
Name*

First NameLast Name
Phone*
Format: (000) 000-0000.
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date

Education & Experience
Highest Level of Education:*
Select a valid license
Other (please specify)
Certified Nursing Assistant (CNA)Personal Care Assistant (PCA)Home Health Aide (HHA)CPR/First Aid CertifiedNone of the aboveOther (please specify)
Certificate #
Enter certificate # if available
Years of Relevant Experience*
Current occupation
List of other professional training:
Upload Resume or Certifications (if available)*

Cancelof

References
Work Reference 1*
Name of Reference
Work Reference 1 Relationship*
Name of Reference
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Work Reference 2
Name of Reference
Work Reference 2 Relationship
Name of Reference
Phone Number
Format: (000) 000-0000.
Email
Personal Reference
Name of Reference
Personal Reference Relationship
Name of Reference
Phone Number
Format: (000) 000-0000.
Email

Background Check Authorization
Please Enter Full Legal Name*

First NameMiddle NameLast Name
Social Security Number*
Only used for the Background Check.Format: 000-00-0000.
Date of Birth*

MonthDayYear
Date
I Please enter your full name* herby give consent for CareAssist, LLC to conduct a background check for the purpose of employment. I am aware that any falsification made in line with this authorization and my employment application shall become a bar for admission of my application.

I authorize that any information acquired by CareAssist, LLC shall solely be used for the application, and the information obtained through this background check will only be used for employment purposes.
Signature*
Print full name*
Date*

MonthDayYear
Date

Submit Application:
By clicking the submit button below, I authorize former employers, references and any other individual/organizations to provide information to CareAssit, LLC, and I hereby release and discharge any of the above and release CareAssit, LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a criminal background check, fingerprint, physical examination if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with CareAssit, LLC.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or currently authorized to work in the United States.

In consideration of my employment, I agree to conform to the hired company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, by either me or the company's option.

"I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law."
Signature*
Print full name*
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Rows	Day Shifts	Night Shifts	Other (Please Specify)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

EMPLOYMENT APPLICATION

Personal Information

Employment & Availability

Professional Conduct Disclosure

Education & Experience

References

Background Check Authorization

Submit Application: