EMPLOYMENT APPLICATION
Internal HR Document | PCS-HR-001 | Version 1.0
Pinnacle Care Solutions is an equal opportunity employer. This application requests job-related information only.
SECTION 1: APPLICANT INFORMATION
Full Legal Name
Preferred Name
Application Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Street Address
City, State, ZIP
Position Applying For
Caregiver
Transportation Assistant
Administrative Support
Other
Employment Type Desired
Full-Time
Part-Time
PRN / As Needed
Weekends Only
Desired Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Desired Hourly Rate
SECTION 2: ELIGIBILITY AND AVAILABILITY
Eligibility
Are you at least 18 years old?
Yes
No
Are you legally authorized to work in the United States?
Yes
No
Will you now or in the future require employer sponsorship? PCS does not sponsor.
Yes
No
Can you perform essential job functions, with or without reasonable accommodation?
Yes
No
Availability
Availability Days
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Availability Times
Morning
Afternoon
Evening
Overnight
Holidays
Short-Notice
Preferred Weekly Hours
Unavailable Days/Times
SECTION 3: TRANSPORTATION AND DRIVING
Reliable transportation to and from work
Yes
No
Valid driver license
Yes
No
Current auto insurance
Yes
No
Willing to transport clients, if assigned and approved
Yes
No
Willing to complete mileage logs when transporting clients
Yes
No
Client transportation may require additional verification, insurance review, and PCS approval before assignment.
Back
Next
EMPLOYMENT APPLICATION
Internal HR Document | PCS-HR-001 | Version 1.0
SECTION 4: EXPERIENCE, CERTIFICATIONS, AND SKILLS
Caregiving/home care experience
Senior care experience
Certifications and Training
CNA
Home Care Certificate
CPR
First Aid
Dementia Care
Medication Reminders
Transfer/Mobility
Other
Certificate/License Details
Expiration Date(s)
Experience and Skills
Companion Care
Meal Preparation
Light Housekeeping
Laundry
Errands/Shopping
Medication Reminders
Bathing Assistance
Dressing Assistance
Grooming Assistance
Toileting Assistance
Transfer Assistance
Mobility Assistance
Fall Prevention
Dementia/Memory Support
Transportation
Documentation/Visit Notes
SECTION 5: EMPLOYMENT HISTORY
Employer 1
Employer Name
Position Held
Dates Employed
Supervisor Name
Phone Number
Format: (000) 000-0000.
Reason for Leaving
May PCS contact this employer?
Yes
No
Employer 2
Employer Name
Position Held
Dates Employed
Supervisor Name
Phone Number
Format: (000) 000-0000.
Reason for Leaving
May PCS contact this employer?
Yes
No
Back
Next
EMPLOYMENT APPLICATION
Internal HR Document | PCS-HR-001 | Version 1.0
SECTION 5: EMPLOYMENT HISTORY CONTINUED
Employer 3
Employer Name
Position Held
Dates Employed
Supervisor Name
Phone Number
Format: (000) 000-0000.
Reason for Leaving
Upload Resume/Certificates
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Should be Empty: