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Arch Home Care

Application for Employment

Name (Last, First, Middle)

Street Address

City, State & Zip

Home Phone

Cellular Phone

 


LICENSE / REGISTRATION / CERTIFICATE. Check all that apply:

Certified Nursing Assistant (C.N.A/ STNA)
CPR/First Aid
LPN
RN
Continuing Education (HIV/ AIDS, Dementia, Mental Health, Diabetes, Dev. Disabilities, etc.)

 

Do you have experience with Developmental Disabilities? Yes No

Do you have experience with long-term care?
Yes No

 

Discuss any training/experience you have in working with the elderly

 

Are you Bilingual? Yes No

If Yes, What language?

How many years of experience do you have providing care to vulnerable adults?

If required for position, do you have a valid driver's license? Yes No

If required for position, do you have current auto insurance? Yes No

 

 
 

 

Prior Criminal Record? Yes No

Charges

Dates?

City, State & Zip

 

Full Time Part Time Any Available

Date you can start work (day/month):

Education:

High School Name

Street Address

City, State & Zip

Diploma? Yes No

 

Vocational School Name

Street Address

City, State & Zip

Diploma/Certificate? Yes No

 

College Name

Street Address

City, State & Zip

Diploma? Yes No

 

 

Currently Employed? Yes No

 

May we contact this employer? Yes No

 


Employer Name


Phone Start/End Dates: Reason for leaving
 

Street Address

City, State & Zip

 

Personal References:

Name

Phone

Relationship 
 

 

Name

Phone

Relationship 
 

 

Name

Phone

Relationship 
 

 

**CERTIFICATION AND RELEASE: By Submitting this application, you agree to the following terms: I certify that I have read and understand the application note on page one of this form 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 misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle 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 understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Type/Sign Full Legal Name

Initial

Date

 

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