Name
Address
City
State Zip
Phone
Cell Landline
Email
Drivers License # Expiration Date State Issued
Do you have daily access to a vehicle? Yes No
Vehicle Year, Make, Model
Auto Insurance Co Policy Number
Do you have any moving violations in the past 7 years? Yes No
If yes, please describe
Emergency Contact: (Name, Phone, Relationship)
Employment References
We make every effort to contact previous employers, correct telephone numbers are essential
Most Recent Employer:
Are you currently working for this employer? Yes No If yes, may we contact this employer? Yes No
Company Dates (Start-End)
Phone City Located
Job Title Supervisor Name
Duties
Rate of pay (per hour, day, etc.) Reason for leaving
Second Most Recent Employer:
Company Dates (Start-End)
Phone City Located
Job Title Supervisor Name
Duties
Rate of pay (per hour, day, etc.) Reason for leaving
Third Most Recent Employer:
Company Dates (Start-End)
Phone City Located
Job Title Supervisor Name
Duties
Rate of pay (per hour, day, etc.) Reason for leaving
Employment Related Skills:
Describe any training you have that applies to service and/or care to the elderly
What do you like (or think you would like) about working with older adults
What do you like least (or think you would like least) about working with older adults
Employment Availability:
Check all that apply
Full-time Part-time Days Early mornings Evenings Weekends Over-nights
Hours per week you wish to work Date able to start work
I am willing to accept Long-term assignments Short-term assignments
I'm avalable Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Do you have reservations of clients With Pets Yes No That smoke Yes No
Do you speak a language other than English No Yes List Language
How far are you willing to travel for work 5 miles/10 min 10 miles/20 min 20 miles/30 min 30 miles/45 min
Education:
Highest Grade Completed Are you a CNA Yes No CNA Certificate Current Expired
School you last attended (name, city, state) Graduated Yes No
Personal References:
Name Phone How Known
Address Years Known
Name Phone How Known
Address Years Known
Name Phone How Known
Address Years Known
I have read and agreed to the Certification and Release




Certification and Release: I certify that I have read and understand the applicant note on the previous page and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize that agency and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If the company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.