* = Required Information
FYI: ConvicMon will not be a deciding factor in conMnuing the pre-screening process or potenMal employment opportuniMes
Educational Background: Please Answer The Following Questions
List previous educational history
What do you think is the most difficult part of caregiving or customer service work?
Ms. Jackson ask you to apply BENGAY muscle rub on her back, what would you do?
In what situations do we provide services not listed in the SERVICE PLAN?
Why is it important to work within your scope or job description?
List your previous employers beginning with the most recent employer.
References: List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please)
Certification and Release
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 informaMon. 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.
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, national origin, ancestry, veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws.