Burdines Homecare & Transportation

Burdines Homecare & Transportation –

Employment Application
Personal Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Information
Position Applying For
Are you legally authorized to work in the United States?

YesNo
Do you have reliable transportation?

YesNo
Are you willing to undergo a background check?

YesNo
Do you have a valid driver's license?

YesNo
Driver's license number?
Driver's license state?
Driver's license expiration date?
Availability
What type of schedule are you looking for?

Full TimePart TimeWeekendsWeekdaysEveningsFlexibleOvernights
Earliest start date

MonthDayYear
Date
Experience
Do you have experience in caregiving or transportation services?
Years of experience
What types of care have you provided?

CompanionshipMeal preparationMedication remindersTransportation to appointmentsLight housekeepingPersonal care (bathing / grooming)Dementia / Alzheimer’s careMobility assistanceHospice support
Certifications (if applicable)

CNAHHACPR / First AidPCAOther
Briefly describe your experience
Previous Employment
Employer #1

Company Name:   Type a label
Position Held:   Type a label
Supervisor Name:   First Name   Last Name
Company Phone Number:   Area Code   Phone Number
Start Date:   Date
End Date:   Date
Reason for Leaving:   Type a label
Employer #2

Company Name:   Type a label
Position Held:   Type a label
Supervisor Name:   First Name   Last Name
Company Phone Number:   Area Code   Phone Number
Start Date:   Date
End Date:   Date
Reason for Leaving:   Type a label
Employer #3

Company Name:   Type a label
Position Held:   Type a label
Supervisor Name:   First Name   Last Name
Company Phone Number:   Area Code   Phone Number
Start Date:   Date
End Date:   Date
Reason for Leaving:   Type a label
References
Reference #1

Name:   Type a label
Relationship:   Type a label
Supervisor Name:   First Name   Last Name
Phone Number:   Area Code   Phone Number
Email:   Email
Reference #2

Name:   Type a label
Relationship:   Type a label
Supervisor Name:   First Name   Last Name
Phone Number:   Area Code   Phone Number
Email:   Email
Resume Upload
Upload Resume

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Additional Questions
Why do you want to work with Burdines Homecare and Transportation?
What qualities make you a good caregiver or team member?
Applicant Agreement & Background Check Consent
By submitting this employment application to Burdines Homecare & Transportation, I certify that the information provided in this application and any attached documents is true, complete, and accurate to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in the rejection of my application or termination of employment if discovered after hiring.

YesNo
I understand that submission of this application does not guarantee employment and that Burdines Homecare & Transportation reserves the right to hire qualified candidates at its sole discretion.

YesNo
I authorize Burdines Homecare & Transportation to verify the information provided in this application, including contacting previous employers, references, and educational institutions for the purpose of evaluating my qualifications for employment.

YesNo
I understand and consent to a background check which may include, but is not limited to:• Criminal history records• Employment verification• Professional reference checks• Driving record verification (if applicable to the position)

YesNo
I authorize all individuals, companies, and organizations listed in this application to release information concerning my employment history, qualifications, and character to Burdines Homecare & Transportation.

YesNo
I release and hold harmless Burdines Homecare & Transportation, its owners, employees, agents, and any third parties providing information from any liability, claims, or damages arising from the verification of information provided in this application or the background screening process.

YesNo
I understand that if employed, my employment will be at-will, meaning that either I or Burdines Homecare & Transportation may terminate employment at any time, with or without cause or notice, unless otherwise required by law.

YesNo
By checking the box below and submitting this application, I acknowledge that I have read, understood, and agree to the terms stated above.

YesNo
Signature
Date

MonthDayYear
Date
Should be Empty:

Burdines Homecare & Transportation –

Personal Information

Position Information

Availability

Experience

Previous Employment

Employer #1

Employer #2

Employer #3

References

Reference #1

Reference #2

Resume Upload

Additional Questions

Applicant Agreement & Background Check Consent