Job Application - Passiontocare

Passion To Care Home Care is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Applicant Name:*

First Last

Address*

Street Address Address Line 2 City State

Telephone Number:*

Email Address:*

Choose one from List A OR a combination of one selection from List B and one selection from List C

List A:

List B:*

List C:*

Are you willing to submit to a background information search required by the Department of Community Health regarding all workers engaged in companion sitter, CNA or similar work?*

Yes
No

please state the reason?*

Are you willing to abide by the company policy related to drug screening which includes, but may not be limited to Post Accident, Random, For Cause or other situations deemed necessary by the company?*

Yes
No

please state the reason?*

Are you able to perform the various functions, that are necessary and consistent with the role of companion sitter or Certified Nursing Assistant?*

Yes
No

Please provide a telephone number with which we may contact you?*

Yes
No

please provide the number:*

Do you have transportation necessary that will allow you to perform the duties associated with a companion sitter or Certified Nursing Assistant?*

Yes
No

Do you live with a senior family relative in the same household?*

Yes
No

Are you CNA certified?*

Yes
No

How did you hear about our company?*

Employment Position

Position(s) applying for: CNA, PCA, Companion Sitter ( full time)

How did you hear about this position?*

What days are you available for work?*

What hours or shift are you available for work?*

On what date can you start working if you are hired?*

Do you have reliable transportation to and from work?*

Personal Information

Do you have CPR / FIRST AID Training?*

Yes
No

Have you ever applied to or worked for Passion To Care Home Care before?*

Yes
No

If yes, when?*

Do you have any friends, relatives, or acquaintances working for Passion To Care Home Care*

Yes
No

If yes, state name & relationship:*

Are you a U.S. citizen or approved to work in the United States?*

Yes
No

What document can you provide as proof of citizenship or legal status?*

Do you have any condition which would require job accommodations?*

Yes
No

If yes, please describe accommodations required below.*

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:*

(Note: Passion To Care Home Carecomplies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional. )

Education and Training

High School*

Name	Location (City, State)	Year Graduated	Degree Earned

College/University*

Name	Location (City, State)	Year Graduated	Degree Earned

Vocational School/Specialized Training*

Name	Location (City, State)	Year Graduated	Degree Earned

Military:

Are you a member of the Armed Services?*

Yes
No

What branch of the military did you enlist?*

What was your military rank when discharged?*

How many years did you serve in the military?*

What military skills do you possess that would be an asset for this position?*

Previous Employment

Please provide 5 years of employment history. If you cannot please provide a reason why.

Employment History*

I will provide
I cant provide

Employer Name:	Job Title:	Employer Address:	City, State and Zip Code:	Employer Telephone:	Dates Employed:		Reason for leaving:

Employer Name:	Job Title:	Employer Address:	City, State and Zip Code:	Employer Telephone:	Dates Employed:		Reason for leaving:

Employer Name:	Job Title:	Employer Address:	City, State and Zip Code:	Employer Telephone:	Dates Employed:		Reason for leaving:

Employer Name:	Job Title:	Employer Address:	City, State and Zip Code:	Employer Telephone:	Dates Employed:		Reason for leaving:

Employer Name:	Job Title:	Employer Address:	City, State and Zip Code:	Employer Telephone:	Dates Employed:		Reason for leaving:

Reason for not providing employment history*

AT-WILL EMPLOYMENT

The relationship between you and the Passion To Care Home Care is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Passion To Care Home Care. No representative of Passion To Care Home Care has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive VicePresident/Chief Operations Officer or the Company's President.

Signature*

Hidden

Dated:*

Career Application Form