Employment Application

Your Name (First, MI, Last) Social Security #
Position Applying For:
Address City State Zip
Email Address Phone Number

Are you legally authorized to work in the United States? Yes No

Have you ever been convicted of a crime other than a minor traffic violation?
Yes No

Do you have a current driver's license? Yes No

Have you had your driver’s license suspended or revoked in past 3 years?
Yes No

Are you applying for: Full time Part time Temporary Any

Are you at least 18 years of age? Yes No


Employment History (Begin with most recent employment)

Dates: From To May We Contact? Yes No

Company Name City/State

Job Title: Duties:

Reason For Leaving

Supervisor's Name Phone Number

Ending Pay



Dates: From To May We Contact? Yes No

Company Name City/State

Job Title: Duties:

Reason For Leaving

Supervisor's Name Phone Number

Ending Pay



Dates: From To May We Contact? Yes No

Company Name City/State

Job Title: Duties:

Reason For Leaving

Supervisor's Name Phone Number

Ending Pay


Education

Highest Level Completed Where Year


Professional Certificates / Licenses:

Type: Expiration Date

Type: Expiration Date


Caregiver Experience

Have you attended a caregiver course, C.N.A., or other formalized training program for this type of work? Yes No

If so, course: Where taken: Date:

Do you have caregiver experience? Yes No

If so, please list:

Name of employer Phone Dates

Name of employer Phone Dates

Name of employer Phone Dates

Do you speak any languages other than English? Yes No
if yes, please list

•• Will you work with a client who is incontinent? Yes No
•• Will you work with a client where most of the work is housekeeping? Yes No
•• Will you work with children? Yes No
•• Can you work around the following: Pets Dust Smoke

What shifts will you work:

Days Evenings Nights Weekends Holidays
Sun Mon Tues Wed Thurs Fri Sat
2-3 hour shift 4-6 hour 8 hour 12 hour 24 hour


Experience Checklist: (Have you worked with or done the following)

Skills: Please check if yes

Toileting Assistance
Given Bed Bath
Change Attends
Walking Assist
Pivot Transfer
Assisted with Meds

Transfer Board
Light Lift
Empty Catheter Bag
Light Housekeeping
Gait Belt
Shower Assist

Hoyer Lift
Full Lift
Meal Prep
Peri-Care
Bowel Care
G-Tube

Diagnoses/Conditions you have worked with:

Alzheimer's/Dementia
CHF
Quadriplegic
ADHD/ADD
Schizophrenia
Mental Illness
Amputee
Other

Diabetes
Parkinson's
COPD
TBI
Bi-Polar
Failure to Thrive
Developmental Delay
Client Receiving Oxygen

Stroke
ALS
Huntington's
Autism
Depression
Hospice
Cancer
Blindness

References

Name Telephone Business or Personal

Name Telephone Business or Personal

Name Telephone Business or Personal


Please list any special qualifications or qualities you possess.




Why should we consider you to work with our clients?




Please read each statement carefully before submitting:

1) I certify that all the information provided in this employment application is true and complete. I understand that any information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

2) I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such person's and organizations from any legal liability in making such statements.

3) I authorize Trinity Home Care & Resource to perform the following & understand that these items need to be completed before starting work
-Criminal Background Report
-Reference Report
-Driver's License Check
-Auto Insurance Check
-TB Test

1) I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and or post-employment drug screen as a condition of employment if required.

2) I consent to the release of any or all medical information as may be deemed necessary to just my capability to do the work for which I am applying.

3) I understand that I am an hourly employee and that this application DOES NOT create a contract of employment, nor guarantee employment for any definite period of time.

I have read, understand, and by submitting, I consent to the above statements.

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