Employment Application

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Background Information
*All Background Information fields are required.

Position Desired

Last Name
First Name
Middle Name

Social Security Number

Street Address

City
State
Zip

Home Phone
Cell Phone
Email Address

Have you ever worked under a different name? If yes, what name?

YesNo

Name of Emergency Contact
Phone Number

Referral Source

How did you hear about FamilyCare Senior Solutions, Inc?
NewspaperFamilyCare WebsiteFriendFormer EmployeeOther

Please list name of friend or former employee so that we can thank them.

Availability

Are you looking for: Full-TimePart-TimePRN

Preferred Work Hours Day TimeEveningsOvernightsWeekends
What date are you available to start?
Are you available on short notice? YesNo

Education

Highest Grade Completed:
High School
College:

High School Attended
Date Graduated

College Attended
Date Graduated

Nurse Aide and/or Personal Care Aide Training Program
Date Graduated Did you take the State Certification Exam? YesNo

Employment History

Please provide your 3 most recent places of employment

Company Name

City
State

Phone

Superviser's Name
Superviser's Title
Primary Responsibilities

Job Title

Dates Worked

From:

To:

Beginning Salary:

Ending Salary:

Reason for Leaving

Company Name

City
State

Phone

Superviser's Name
Superviser's Title
Primary Responsibilities

Job Title

Dates Worked

From:

To:

Beginning Salary:

Ending Salary:

Reason for Leaving

Company Name

City
State

Phone

Superviser's Name
Superviser's Title
Primary Responsibilities

Job Title

Dates Worked

From:

To:

Beginning Salary:

Ending Salary:

Reason for Leaving

Background Information

Have you been convicted of a crime or do you have any charges currently pending?
YesNo
If Yes, please explain and provide dates:
Are you legally authorized to work in this country?
YesNo
FamilyCare has a Drug Free Workplace policy. Do you agree to adhere to this policy?
YesNo
Have you ever been employed in a position where you were required to handle cash?
YesNo
I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that if hired, that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application.
YesNo

I also understand that if my assignment ends I will report to FamilyCare Senior Solutions, Inc within 48 hours for another assignment. Failure to do so and/or refusal of future assigned cases will indicate voluntary resignation and result in ineligibility for unemployment.
YesNo


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