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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