Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment Attach additional sheet(s) if necessary.

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employmentmay jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Caring with a Purpose Home Care LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Caring with a Purpose Home Care LLC with regard to any of the subjects covered by this application. I also understand thatin connection with my application for employment or my employment, Caring with a Purpose Home Care LLC may conduct a criminal background investigation and that my employment may be contingenton the results of such investigation. I release Caring with a Purpose Home Care LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information aboutme, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Caring with a Purpose Home Care LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Caring with a Purpose Home Care LLC or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Caring with a Purpose Home Care LLC, at any time, can constitute a contract of employment No representative or agent of Caring with a Purpose Home Care LLC, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submitto a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Caring with a Purpose Home Care LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional's practice. The Professional fully indemnifies Caring with a Purpose Home Care LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

Background Check and Driving Record Authorization

I hereby authorize the Caring with a Purpose Home Care to conduct a background check and review my driving record as part of the application and screening process. I understand that this review may include verification of my criminal history, driving history, and other relevant records as permitted by law.

By submitting this application, I give my consent for these checks to be performed. I also acknowledge that I am required to upload a clear copy of my valid driver’s license and/or government-issued identification to complete the application process.

Upload Driver License and/or goverment-issued identification