• PCA/CDS Attendant Employment Application

    Applicants are not required to give information prohibit by Federal, State/Provincial or Local Law.

  • Applicant Information

  • Application Date: *
     - -
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Date Available To Start Work*
     - -

  • Work Availability (Required)

  • I am willing to work:*

  • Caregiver Scheduling Requirements

    Circle of Care St. Louis provides Home and Community-Based Services (HCBS) seven (7) days a week. Caregiver schedules are based on client needs, employee availability, and business necessity.

    All caregivers are required to:

    • Work a minimum of two (2) weekends per month.
    • Be available to work at least six (6) consecutive hours on both Saturday and Sunday when scheduled.
    • Accept assignments based on client needs.
    • Work with one or more clients during a scheduled workday, when assigned.

    Please provide your actual availability below.

  • Monday Earliest Available Time*
  • Monday Latest Available Time*
  • Tuesday Earliest Available Time*
  • Tuesday Latest Available Time*
  • Wednesday Earliest Available Time*
  • Wednesday Latest Available Time*
  • Thursday Earliest Available Time*
  • Thursday Latest Available Time*
  • Friday Earliest Available Time*
  • Friday Latest Available Time*
  • Saturday Earliest Available Time*
  • Saturday Latest Available Time*
  • Sunday Earliest Available Time*
  • Sunday Latest Available Time*
  • Please initial each statement.*
  • Are you a U.S. citizen?*
  • Are you authorized to work in the U.S.?*
  • Do you have a Government ID? Must not be expired.*
  • What type of Government ID do you have?*
  • Do you have your social security card?*
  • Has your driver’s license ever been suspended or revoked?*
  • Have you ever gone by a different name?*
  • Have you ever entered a plea of guilty or nolo contendere or been convicted of a felony or of anything other than a minor traffic accident?*
  • Have you ever been on the Employment Disqualification List (EDL)*
  • Have you ever lived in any other state other than Missouri?*
  • Have you ever been bonded?*
  • Have you ever been denied bond coverage?*

  • Educational Background 

    List the last three schools attended, starting with the last one. 

  • Did you graduate?*
  • Did you graduate?
  • Did you graduate?

  • Employment History

    Please provide a complete record of your work experience for the past five (5) years, beginning with your current or most recent position. Include all full-time and part-time employment, as well as any periods of volunteer work, internships, or community service. If you were unemployed during any period, please explain.
  • Employment Start Date: *
     - -
  • Employment End Date:
     - -
  • Format: (000) 000-0000.
  • Is this position relevant to your caregiving experience?*

  • Reference Check (Current Employer Only)

  • (Employment verification will be conducted with this employer as part of the background check process.)

  • May we contact your employer at this time for a reference?*
  • Employment Start Date:
     - -
  • Employment End Date:
     - -
  • Format: (000) 000-0000.
  • Is this position relevant to your caregiving experience?
  • Employment Start Date:
     - -
  • Employment End Date
     - -
  • Format: (000) 000-0000.
  • Is this position relevant to your caregiving experience?
  • Employment Start Date:
     - -
  • Employment End Date:
     - -
  • Format: (000) 000-0000.
  • Is this position relevant to your caregiving experience?
  • Employment Start Date:
     - -
  • Employment End Date:
     - -
  • Format: (000) 000-0000.
  • Is this position relevant to your caregiving experience?
  • Employment Start Date:
     - -
  • Employment End Date:
     - -
  • Format: (000) 000-0000.
  • Is this position relevant to your caregiving experience?

  • Gaps in Employment

  • References

  • References – Instructions

    Please provide two individuals who can speak to your professional qualifications or personal character. Do not list relatives.

    • A professional reference is someone who knows you in a work or volunteer setting and can speak to your skills, work ethic, or job performance (e.g., supervisor, coworker, mentor).
    • A personal reference is someone who knows you outside of work and can speak to your character, reliability, and integrity (e.g., teacher, coach, community leader, or longtime family friend).
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • The information I have provided is complete and accurate to the best of my knowledge. I also understand that providing the information may disqualify me from further consideration. I also authorize this agency to make any investigation(s) of my personal, financial, and/or credit background (including, but not limited to) obtaining a credit report (also known as a “consumer report” under the Fair Credit Reporting Act/Consumer Reporting Act) for the purpose of evaluating my qualifications for employment. This authorization extends for twelve months from today’s date.

  • Date:*
     - -
  • Should be Empty: