First Name*

Last Name*

Your email*

Street Address*

Address Line 2

City*

State*

Postal/Zip Code*

Phone Number*

Social Security Number*

Date of Birth*

ARE YOU EITHER A US CITIZEN OR ALIEN AUTHORIZED TO WORK IN THE UNITED STATES?*
YesNo

ARE YOU AT LEAST EIGHTEEN (18) YEARS OF AGE?*
YesNo

Resume Upload

Have you ever used an alias or different social security?*
YesNo

If yes, please list all aliases or social security numbers:

Has your name ever been placed on the Employee Disqualification List for any period?*
YesNo

If yes, please explain:

Have you ever been named as a perpetrator of abuse/neglect or exploitation of a child, elderly person or an adult by a state agency in a case where the state agency determined that the allegations against you were valid or substantiated?*
YesNo

If yes, please explain:

Have you ever plead guilty, nolo contendere or been convicted of any crime, misdemeanor or felony, in this state or any other state, except minor traffic offenses?*
YesNo

If yes, please explain:

Desired Position*
Personal Care AssistantPRN - Guaranteed Hour Position

Date You Can Start*

CURRENTLY EMPLOYED*
YesNo

HAVE YOU EVER APPLIED TO THIS AGENCY BEFORE?*
YesNo

ARE YOU REGISTERED WITH THE FAMILY CARE SAFETY REGISTRY MAINTAINED BY THE DEPARTMENT OF HEALTH AND SENIOR SERVICES?*
YesNo

CAN YOU WORK IN A HOME WITH A CLIENT WHO SMOKES CIGARETTES?*
Heavy SmokerLight Smoker OnlyYesNo

CAN YOU WORK IN A HOME WITH CATS?*
YesNo

CAN YOU WORK IN A HOME WITH DOGS?*
YesNo

IS THERE ANY REASON WHY YOU WOULD NOT BE ABLE TO PERFORM THE JOB DUTIES?*
YesNo

ARE YOU ABLE TO LIFT AT LEAST 50 LBS?*
YesNo

ARE YOU ABLE TO CLIMB STAIRS WITHOUT DIFFICULTY?*
YesNo

DO YOU HAVE A SKILLED LICENSE/CERTIFICATION? IF YES, LIST TYPE:

HOW DID YOU LEARN OF THIS POSITION?*

DO YOU HAVE A VALID DRIVER'S LICENSE?*
YesNo

DO YOU HAVE CURRENT PROOF OF AUTO INSURANCE?*
YesNo

DO YOU HAVE A CURRENT TB SKIN TEST (within the last 12 months) ?*
YesNo

IF YOU DO NOT HAVE A CURRENT TB SKIN TEST, WOULD YOU BE WILLING TO TAKE ONE AT YOUR LOCAL HEALTH DEPT OR DOCTORS OFFICE?*
YesNo

DO YOU HAVE ANY EXPERIENCE WORKING WITH PERSON WHO HAVE PHYSICAL/COGNITIVE DISABILITIES?*
YesNo

IF YES, PLEASE EXPLAIN THE DUTIES.

HAVE YOU EVER FILED FOR WORKER COMPENSATION?*
YesNo

IF YES, PLEASE EXPLAIN.

WORK PREFERENCES AND AVAILABILITY

DO YOU PREFER WORKING WITH MALES, FEMALES, OR EITHER?*
MenWomenEither

SELECT ALL DAYS OF THE WEEK THAT YOU ARE AVAILABLE:*
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Check All That Apply*
MorningsAfternoonsEvenings

PLEASE CHECK THE FOLLOWING DUTIES THAT YOU ARE WILLING AND ABLE TO PERFORM ON A DAILY BASIS:*
Toilet RoutineShoweringDressingTransfersMeal PreparationsFeedingErrands/LaundryHousekeeping

COMMENTS

Highest Education:*
Didn't Finish GED/High SchoolGED/High SchoolSome CollegeAssociatesBachelorMasters

Last Institution Attended*

DO YOU HAVE PHYSICAL LIMITATIONS THAT PRECLUDE YOU FROM PERFORMING ANY WORK FOR WHICH YOU ARE BEING CONSIDERED?*
YesNo

IF YES, WHAT CAN BE DONE TO ACCOMMODATE YOUR LIMITATION?

IN CASE OF EMERGENCY, PLEASE NOTIFY:

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for termination.

I authorize my consent to pre-employment criminal record check.
I authorize my consent for closed records check.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they have, personal or otherwise, and release all parties from liability for damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may regardless of the date of payment of my wages and salary, be terminated at any time without notice."

Please type First and Last name if you consent.*