JOB APPLICATION

JOB APPLICATION

A LOVING TOUCH SENIOR CARE SERVICES, LLC | 232 Market St Bldg K Ste 257, Flowood, Mississippi 39232 | 601·914-7273
A LOVING TOUCH SENIOR CARE SERVICES is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:
Applicant Information
Applicant Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Application*

MonthDayYear
Employment Position
Position(s) applying for: (Full time only)*

Personal Care AttendantDirect Care Worker
How did you hear about this position? *
What days are you available for work?*
What days are you available for work?*
If needed, are you available to work overtime?*
On what date can you start working if you are hired?*
Do you have reliable transportation to and from work?*
Personal Information
Have you ever applied to or worked for A LOVING TOUCH SENIOR CARE SERVICES before?*

YesNo
If yes, when?
Do you have any friends, relatives, or acquaintances working for A LOVING TOUCH SENIOR CARE SERVICES, LLC?*

YesNo
If yes, state name & relationship:
Are you 18 years of age or older?*

YesNo
Are you a U.S. citizen or approved to work in the United States?*

YesNo
What document can you provide as proof of citizenship or legal status?*
Will you consent to a mandatory controlled substance test?*

YesNo
Do you have any condition which would require job accommodations?*

YesNo
If yes, please describe accommodations required below
Have you ever been convicted of a criminal offense (felony or misdemeanor)?*

YesNo
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:
Job Skills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying:*
(Note: A LOVING TOUCH SENIOR CARE SERVICES complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)
Education and Training

Type "N/A" if an item is not applicable.
High School*
Location (City, State)*
Year Graduated*
Degree Earned*
College/University*
Location (City, State)*
Year Graduated*
Degree Earned*
Vocational School/Specialized Training *
Location (City, State)*
Year Graduated*
Degree Earned*
Military

Type "N/A" if an item is not applicable.
Are you a member of the Armed Services? *
What branch of the military did you enlist?*
What was your military rank when discharged?*
How many years did you serve in the military?*
What military skills do you possess that would be an asset for this position?*
Previous Employment

Type "N/A" if an item is not applicable.
Employer Name*
Job Title*
Supervisor Name*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Telephone*
Dates Employed*
Reason for leaving:*
Employer Name*
Job Title*
Supervisor Name*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Telephone*
Dates Employed*
Reason for leaving*
Employer Name*
Job Title*
Supervisor Name*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Telephone*
Dates Employed*
Reason for leaving*
References

Please provide 3 personal and professional reference(s) below:
1st Reference*
Contact Information*
2nd Reference*
Contact Information*
3rd Reference*
Contact Information*
AT-WILL EMPLOYMENT

The relationship between you and the A LOVING TOUCH SENIOR CARE SERVICES is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the A LOVING TOUCH SENIOR CARE SERVICES. No representative of A LOVING TOUCH SENIOR CARE SERVICES has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.
Applicant Signature*

Hold down the left click button and move cursor to sign.
Date*

MonthDayYear
Please verify that you are human*
Should be Empty:

JOB APPLICATION

Applicant Information

Employment Position

Personal Information

Job Skills/Qualifications

Education and Training

Military

Previous Employment

References