Employment Application

    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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