Application for Employment
Name
*
First Name
Last Name
Birthday
*
/
Month
/
Day
Year
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Race/ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Driver License/ID
*
Social Security Number
*
Gender/Sex
Please Select
Female
Male
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a U.S Citizen?
*
Yes
No
Other
Certifications (CPR, CNA, RN, LPN, etc..)
Browse Files
Drag and drop files here
Choose a file
Please click on the "Browse Files" sign to add more.
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of
Upload photo
*
Photo
Drag and drop files here
Choose a file
Name Tag Required
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of
Driver Lis/ ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Car Insurance
Photo
Drag and drop files here
Choose a file
Name Tag Required
Cancel
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Please select availability:
Rows
Day Shifts (Mornings)
Day Shifts (Mid Afternoon)
Nights
Specify other
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Select the counties below you are able to service
*
Saginaw
Gladwin
Isabella
Tuscola
Baycity
Clare
Gratiot
Sanilac
Other
Have you been vaccinated against COVID-19?
Yes, fully vaccinated
No
Partially yes (only one dose)
Other
Do You Have Transportation?
*
Yes
No
Other
Will you be providing services for a love one?
*
Yes
No
Other
Any Felony Convictions?
*
Yes
No
Other
Reference
*
Rows
Name
Title
Phone
email
Personal Reference
Professional Reference
CONFIDENTIAL: Background Check Authorization: The information contained in this application is correct to the best of my knowledge. I hereby authorize Serenity Homecare Solutions to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize Serenity Homecare Solutions to divulge any and all information, verbal or written, pertaining to me, to or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. Serenity Homecare Solutions shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth. Any question or explanations of chargers please submit below
*
Please verify that you are human
*
Signature
*
Date
*
-
Month
-
Day
Year
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