Employment Application

Please complete this application as completely and accurately as possible.
Name
Last
First
Middle
Social Security Number
Home Telephone Number
Cell Phone/Pager Number
E-mail Address
Address
State
Zip Code
Are you over the age of 18?

Yes No
Are you a US citizen?

Yes No
If no, do you have the legal right and necessary documents to work in the US? (Identity and employment eligibility will be verified as required by law.)

Yes No
Employment Information
Position Desired
....

Part time Full time
Shift Preference
Salary desired?
Do you possess a valid driver's license?

Yes No
Do you have your own transportation?

Yes No
Have you applied here before?

Yes No
If so, when?
How were you referred to us?

Classified Advertisement Care Matters Website Referred Other
Name of person that referred you.
If other, please tell us
Qualifications and Experience

Education
High School
Did you graduate?

Yes No
Year of graduation
College
Did you graduate?

Yes No
Year of graduation
Technical
Did you graduate?

Yes No
Year of graduation
Languages spoken in addition to English
Can you perform all of the job-related functions of the position(s) for which you are applying?

Yes No
If no, please explain
Do you have a current CPR certification?

Yes No
Expiration Date
First Aid certification?

Yes No
Expiration Date
Willing to Perfom

CNA Personal Care
....

Bathing Grooming Dental Care Shaving Record Vital Signs Med Reminder Observing/Reporting Documenting Intake and Output Ambulation Transfer Toileting Dressing Eating
....

Transport/Escort Recreation/Playing Games Grocery Shopping Errands Change Linens Light Housekeeping Shopping Planning Stimulating Activities Laundry Phone Calls Mail Feed Pets Prepare Meals
Current Employer
Name
Address
Position
Phone Number
Date Started
Salary
May we contact?

Yes No
Supervisor
Reason for leaving
Past Employers
Name
Address
Position
May we contact?

Yes No
Phone Number
Date Started
Date Ended
Salary
Supervisor
Reason for leaving
Name
Address
Position
May we contact?

Yes No
Phone
Date Started
Date Ended
Salary
Supervisor
Reason for leaving
Name
Address
Position
May we contact?

Yes No
Phone
Date Started
Date Ended
Salary
Supervisor
Reasong for leaving
References

(Give work or medical field related references. Do not list relatives or personal friends.)
Name
Phone
Years Acquainted
Name
Phone
Years Acquainted
Name
Phone
Years Acquainted
Criminal Background Inquiry
Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime?

Yes No
If yes, please explain: (You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.)
Emergency Contact
Name
Address
Phone
Relationship
"I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for any damage for issuing such information." "I understand that neither this document nor any offer of employment from the employer constitutes an employment contract. Furthermore, I understand that any employment is "at will," which means that either I or Care Matters, Inc may terminate my employment at any time with or without cause, reason, or notice. In making this application for employment, I agree to submit to a post-offer pre-employment drug and health screen. Should the results of this screen be unsatisfactory in the judgement of Care Matters, Inc, the job offer will be withdrawn. My signature is an acknowledgement that I have read and understand this document.
Signature
Date
Care Matters, Inc is an equal opportunity employer. Care Matters, Inc considers applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of disability, or any other legally protected status.
Should be Empty: