Careers Form

* = Required Information

PERSONAL DATA

Date Application Completed

Last Name *

First Name *

Middle Name

Home Phone *

Other Number

Pager / Cellular Number

Email Address

Date of Birth

Social Security Number

Gender

Female

Male

Languages you speak

Minimum hours you will work in 1 day

Maximum in 1 day

How far will you travel? (in miles)

Do you have the following: CNA, CPR, HHR, First Aide?

Yes

Address (if less than one year provide your previous address)

City *

State

Zip Code*

Length of Residence

Previous Address

City

State

Zip Code

Length of Residence

JOB INTERESTS

Position Applying For *

How were you referred to us?

Date Available for Work? *

Anticipated Wage *

Please check the specialty area(s) that best match (as) your experience / education and interested

Please indicate your availability or interest below

EDUCATION

Name of College or Undergraduate Education / School

Degree

Year Graduated

Name of College or Undergraduate Education / School

Degree

Year Graduated

GENERAL INFORMATION

Are you legally authorized to work in the USA?

Yes

If you become an employee of this Agency you will be required to provide documentation proving your eligibility to work in the USA

Have you ever been convicted of a felony or a misdemeanor crime? ( This does not apply if the conviction has been expunged, is contained on a sealed record, or was a juvenile conviction. )

Yes

If yes, state the basis for each conviction and the date of the conviction

Have you ever been employed by this Agency or one of its subsidiaries?

Yes

If yes, give location and dates

In case of emergency, notify

Phone

Relationship

PERSONAL REFERENCES

Please furnish three references with complete address. Do not list former employers or relatives. The individuals you list should have known or at least one year

Name

Address (Include city, state and zip)

Phone Number

Business

Years Known

Name

Address (Include city, state and zip)

Phone Number

Business

Years Known

Name

Address (Include city, state and zip)

Phone Number

Business

Years Known

WORK HISTORY

Company Name (present or most recent employer)

Employment Dates

From

Company Address

City

State

Wage

Per Hour

Annual

Describe your Job Responsibilities and Duties

Supervisor's Name

Telephone Number

May We Contact

Yes

Reason for Leaving

Company Name

Employment Dates

From

Company Address

City

State

Wage

Per Hour

Annual

Describe your Job Responsibilities and Duties

Supervisor's Name

Telephone Number

May We Contact

Yes

Reason for Leaving

Company Name

Employment Dates

From

Company Address

City

State

Wage

Per Hour

Annual

Describe your Job Responsibilities and Duties

Supervisor's Name

Telephone Number

May We Contact

Yes

Reason for Leaving

Company Name

Employment Dates

From

Company Address

City

State

Wage

Per Hour

Annual

Describe your Job Responsibilities and Duties

Supervisor's Name

Telephone Number

May We Contact

Yes

Reason for Leaving

In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulation, Gentle Love and Care is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRMINATE AGAINST RACE, COLOR, SEX, CREED, NATIONAL ORIGIN OR COMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation, Gentle Love and Care, WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulation, Gentle Love and Care, WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services, unless age is a factor necessary to the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1992 (42 USC §12101) and its implementing regulations, (private employers with more than 25 agency personnel), Gentle Love and Care, WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment that substantially limits a major life activity, or for which ther is a record of impairment or which causes the individual to be regarded as impaired.

The information that I have given is true and accurate to the best of my knowledge

Signature of Applicant

Date

Attach Resume

Full Time	Part Time	Short Notice	Split Shift - am/pm
PRN / live in

Homecare	Medical / Surgical	IV Therapy	Intermittent Care	Private Duty
Hospice	Rehabilitation	Pediatrics / Maternal Child	Supplemental Staffing	Residential Care
Nursing Home	Hospital	Geriatic	Psychiatric	Homemaking

7am - 3pm	3pm - 11pm
11pm - 7pm	Visit Only

Monday	Tuesday
Wednesday	Thursday
Friday	Saturday
Sunday