Caregivers - Application for Employment

CAREGIVERS APPLICATION FOR EMPLOYMENT

A PINEYWOODS APPLICATION FOR EMPLOYMENT
Name

First NameLast Name
Have you ever worked under another name? If so, please list that name:
Are you at least 18 years old?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email (Only used for work communication purposes)
example@example.com
Desired Waged (hourly payment)?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever been convicted of a felony? (Conviction will not necessarily disqualify an applicant for employment)
If yes, describe conditions:
Are you a certified nurse aide (CNA)?
If you are a CNA, please provide your CNA number:
Please provide your valid Driver's License number:
Do you have transportation?
Do you have liability insurance on your vehicle?
Have you ever worked for us before?
If yes, reason for leaving:
Do you have experience in this field?
Work History

Please enter your work history below.
May we contact your present employer?
Name of Most Recent Employer?
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Starting salary
Starting position
Date Left

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Previous Employer 1
Name of Previous Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Starting salary
Starting position
Date Left

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Previous Employer 2
Name of Previous Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Starting salary
Starting position
Date Left

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Previous Employer 3
Name of Previous Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Starting salary
Starting position
Date Left

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Salary on leaving
Name and Title of Supervisor
Description of Duties
Reason for leaving
Reference 1
Name of Reference

First NameLast Name
Years Known
Phone Number of Reference
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2
Name of Reference

First NameLast Name
Years Known
Phone Number of Reference
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3
Name of Reference

First NameLast Name
Years Known
Phone Number of Reference
Please enter a valid phone number.Format: (000) 000-0000.
Final acknowledgements

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Company to make an investigation of any of the facts set forth in this application and release the Company from any liability.

I understand that employment at this Company is “at-will,” which means that either I or the Company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I understand that no supervisor, manager, or executive of the Company, other than the president in a signed writing has any authority to alter the foregoing.
Check this box if you agree and certify the above statements.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Should be Empty:

CAREGIVERS APPLICATION FOR EMPLOYMENT

Work History

Previous Employer 1

Previous Employer 2

Previous Employer 3

Reference 1

Reference 2

Reference 3