Platinum Signature Care - Employment Application
Note : This position requires a background screening, must be able to pass a level 2 background check.
Streamlined application | PCA, CNA and home care staff
1. Applicant Information
Name
*
First Name
Middle Initial
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Are you age 18 or older?
Yes
No
Authorized to work in the U.S.?
Yes
No
2. Position and Availability
Position applied for
Application date
-
Month
-
Day
Year
Date
Earliest start date
-
Month
-
Day
Year
Date
Employment desired
Full-time
Part-time
Temporary/PRN
Desired hourly rate
Hours available per week
Available weekends?
Yes
No
Overnights?
Yes
No
General availability (days and times)
3. Transportation and Placement
Reliable transportation for home visits?
Yes
No
Transportation type
Valid driver license?
Yes
No
License state
License class
Any pet allergies?
Yes
No
Able to work in a smoking home?
Yes
No
Placement limitations or notes
Back
Next
Qualifications and Background
4. Licenses, Certifications and Clearances
CNA license
HHA certification
CPR certification
BLS certification
Child abuse clearance
FBI background check
State background check
Current physical
TB/PPD screening
Chest X-ray, if required
Other license/certification
License/certification number
Expiration date
Years of caregiving experience
5. Education and Skills
Highest education completed
School name
City/state
Diploma, degree or certificate
Relevant training or skills
Equipment you can safely operate
Languages spoken
Professional specialty/strength
6. Screening Questions
Have you worked for Platinum Signature Care before?
Yes
No
If yes, when?
May we contact your current employer?
Yes
No
Employment History
7.1 Employment History - Employer 1
Employer name
Job title
City/state
Start date
-
Month
-
Day
Year
Date
End date
-
Month
-
Day
Year
Date
Supervisor name
Supervisor phone
Format: (000) 000-0000.
May contact?
Yes
No
Primary duties
Reason for leaving
7.2 Employment History - Employer 2
Employer name
Job title
City/state
Start date
-
Month
-
Day
Year
Date
End date
-
Month
-
Day
Year
Date
Supervisor name
Supervisor phone
Format: (000) 000-0000.
May contact?
Yes
No
Primary duties
Reason for leaving
References, Authorizations and Acknowledgments
8. Professional References
Reference 1 name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
Reference 2 name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
9. Applicant Certification and Authorization
I certify that the information in this application is true and complete to the best of my knowledge. I authorize Platinum Signature Care and its authorized agents to verify employment, education, professional references, licenses, driving history and legally permitted background information for employment purposes. I understand that any offer may be conditional upon satisfactory verification and required clearances. I understand employment is at will and that hours or assignments are not guaranteed.
I have read and agree to the certification and authorization above.
Applicant signature
Date
-
Month
-
Day
Year
Date
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