Caring Helpers - employee application

employee application

POSITION APPLYING FOR: *COMPANIONP.C.A.C.N.A.L.P.N.R.N.
LAST NAME: *
FIRST NAME *
M.I. *
ADDRESS STREET: *
ADDRESS CITY: *
ADDRESS STATE: *
ADDRESS ZIPCODE: *
DATE OF BIRTH* * *YOU MUST BE AT LEAST 18 YEARS OF AGE.
SOCIAL SECURITY NUMBER: *
HOME PHONE NUMBER:
CELL PHONE NUMBER:
EMAIL ADDRESS: *
AVAILABLE START DATE:
U.S. CITIZEN: *YESNO
IF NO, ARE YOU AUTHORIZED TO WORK IN THE UNITED STATES?YESNO
POSITION APPLYING FOR: *FULL TIMEPART TIME
EXPECTED PAY REATE:
ARE YOU CURRENTLY EMPLOYED *YESNO
CURRENT PAY RATE:
WHEN WAS THE LAST TIME YOU HAD tb TEST OR X-RAY DONE? *
DO YOU HAVE ANY SCRUBS/UNIFORM? * (SCRUBS / UNIFORMS AND CLOSED TOE SHOES ARE MANDETORY ON ALL ASSIGNMENTS)YESNO

HIGH SCHOOL NAME: *
HIGH SCHOOL CITY: *
HIGH SCHOOL STATE: *
DID YOU GRADUATE? *YESNO
DID YOU GET YOUR G.E.D.?YESNO
COLLEGE NAME:
COLLEGE CITY:
COLLEGE STATE:
DID YOU COMPLETE COLLEGE?YESNO
DIPLOMA/DEGREE
DESCRIBE COURSE OF STUDY:
OTHER EDUCATION:
OTHER CITY:
OTHER STATE:
DID YOU COMPLETE YOUR OTHER STUDIES?YESNO
CERTIFICATION/DIPLOMA/DEGREE
DESCRIBE COURSE OF STUDY:
DO YOU HAVE ANY CERTIFICATION / LICENSE: *YESNO
LICENSE NUMBER: *
EXP. DATE:
IS OR HAS YOUR LICENSE EVER BEEN RESTRICTED OR REVOKED? *YESNO
IF YES, EXPLAIN:
DO YOU READ, WRITE AND / OR SPEAK FLUENTLY IN:OTHERFRENCHGERMANSPANISH
IF OTHER LANGUAGE, PLEASE LIST:

COMPANY: *
SUPERVISOR:
ADDRESS:
CITY:
STATE:
ZIPCODE:
START DATE:
END DATE:
PAY RATE:
RESPONSIBILITIES:
REASON FOR LEAVING:
MAY WE CONTACT YOUR PREVIOUS SUPERVISOR FOR A REFERENCE? *YESNO
COMPANY: *
SUPERVISOR *
ADDRESS:
CITY:
STATE:
ZIPCODE:
START DATE:
END DATE:
PAY RATE:
RESPONSIBILITIES:
REASON FOR LEAVING:
MAY WE CONTACT YOUR PREVIOUS SUPERVISOR FOR A REFERENCE? *YESNO

HAVE YOU EVER BEEN ARRESTED OR CONVISTED OF ANY CRIME? *YESNO
IF YES, EXPLAIN:
HAVE YOU EVER BEEN CONVICTED OF A FELONY? *YESNO
IF YES, EXPLAIN:
HAVE YOU EVER BEEN CONVICTED OF MAJOR / MINOR TRAFFIC VIOLATIONS? *YESNO
IF YES, EXPLAIN:

LICENSE NUMBER?
STATE ISSUED:
EXPIRATION DATE:
HAS YOUR LICENSE EVER BEEN SUSPENDED OR RECOKED? *YESNO
IF YES, EXPLAIN:
DO YOU HAVE PERSONAL AUTOMOBILE INSURANCE? *YESNO
IF NO, EXPLAIN:
YOUR METHOD OF TRANSPORTATION: *DRIVEDROP-OFFPUBLIC TRANSPORTATIONOTHER
IF OTHER PLEASE EXPLAIN:

DO YOU HAVE ANY PRIOR COMMITMENTS TO ANY PERSON(S), SCHOOL, EMPLOYER, OR ORGANIZATION THAT MAY AFFECT YOUR EMPLOYMENT / SCHEDULE? *YESNO
IF YES, EXPLAIN:
DO YOU HAVE ANY PHYSICAL OR MEDICAL CONDITION THAT MAY HINDER OR PREVENT YOU FROM PERFORMING ANY ACTIVITIES? *YESNO
IF YES, EXPLAIN:

AUTHORIZATION TO RELEASE INFORMATION

As an applicant for a position with "CARING HELPERS", I have been asked to furnish information for use in reviewing my background and qualifications. I hereby authorize the investigation of my past and present work history, character,education, background histroy and police records to ascertain any and all information which may be pertinent to my employment qualifications with this company. This includes all information contained in my employment records.

If this applicaiton leads to employment, I understand that false or misleading information in my application or interview may result in my immediate termination.

I understand that this authorization shall be valid for 90 days form the date of my signature below. And the information will be handled confidentially in compliance with all applicable Federal laws.

^Filling out fields below will consitute for a digital signature for this form.

^FULL NAME FOR DIGITAL SIGNATURE: *
DATE: *