Employment Application
PERSONAL INFORMATION
Name:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Driver's License / ID #:
*
State:
*
Position Applying For:
*
Hours Available Per Week:
*
CAREGIVER AVAILABILITY
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
SERVICE AREAS & TRANSPORTATION
New Castle County Kent County
*
New Castle County
Kent County
*
I have reliable transportation.
I possess a valid driver's license.
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*
I maintain current automobile insurance.
EDUCATION
College / Graduate School:
Trade / Technical School:
High School:
EMPLOYMENT HISTORY
Employer #1
Company:
*
Phone:
*
Format: (000) 000-0000.
Dates Employed:
*
Job Title / Duties:
*
Reason for Leaving:
*
Employer #2
Company:
Phone:
Format: (000) 000-0000.
Dates Employed:
Job Title / Duties:
Reason for Leaving:
Employer #3
Company:
Phone:
Format: (000) 000-0000.
Dates Employed:
Job Title / Duties:
Reason for Leaving:
REFERENCES
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Reference #1 Name:
*
Phone:
*
Format: (000) 000-0000.
City:
State:
Reference #2 Name:
*
Phone:
*
Format: (000) 000-0000.
City:
State:
EMPLOYMENT SCREENING ACKNOWLEDGMENT
*
Delaware BCC Fingerprint Background Check
Drug Screening
Delaware Adult Abuse Registry (DAAR) Screening
Employment Verification and Delaware Service Letter Requests
Employment is contingent upon satisfactory screening results
CRIMINAL HISTORY
Have you been convicted of a crime within the last five (5) years?
*
Yes
No
If yes, please explain:
SPECIAL SKILLS, QUALIFICATIONS & EXPERIENCE
Please describe any caregiving, home care, healthcare, customer service, household management, transportation, companionship, dementia care, or other relevant experience, skills, certifications, or training.
APPLICANT CERTIFICATION
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I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in disqualification from employment consideration or termination of employment if discovered after hire. I authorize Medallion Home Care of DE to verify employment history, references, and information provided within this application.
Applicant Signature:
*
Date:
*
-
Month
-
Day
Year
Date
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