EMPLOYMENT APPLICATION
Position: Companion
The Companion is responsible for transportation, meal preparation, shopping, "light" housekeeping, etc. Responsiblities do NOT include "heavy" housekeeping, outdoor maintenance or medical treatment.
APPLICANT DATA
1. Last Name
2. First Name
3. Middle Name
4. Date of Birth (if under 18)
5. Street Address
6. City
7. State
8. Zip Code
9. Phone
10. Social Security Number
11. Are you Authorized to work in the US? Yes No
12. Category of Work Full Time Part Time Temporary
13. Date Available
14. What days can you work? M T W TH F SA SU
15. What hours can you work?
16. Have you ever applied with us before? No Yes - When?
17. Have you ever worked for us before? No Yes - When?
EDUCATION
18. Check Grade Completed 7th 8th 9th 10th 11th 12th
19. Last High School Attended
20. Major Course of Study
21. College, Technical, Trade or Other
22. Name of School
23. Major Course of Study
24. Degree or Diploma Granted
If you are an RN, LPN, CNA, CHNA or PCA
25. Please check areas in which you have experience or interest:
Hospital Nursing Home Home Health Charge Administration Adult Care Facility
Professional Licensure/Registration Data
26. License Number
27. Expiration Date
SKILLS
28. Please check areas in which you have had experience or training:
Data Processing Typewriter Switchboard Medical Terminology
Other
WORK HISTORY
29. Please provide the names of your most recent employers complete with Company Names and Addresses, Dates of Employment and Positions or Duties.
PERSONAL REFERENCES
30. Please provide Names, Addresses and Phone Numbers.
31. Excluding traffic violations, have ever been convicted of a crime? Yes No
32. If yes, describe in full...
33. Do you accept the possibility of working weekends, holidays, or rotation shifts? Yes No
34. Do you understand that, due to the nature of the services we provide, an exceptional record of attendance, promptness and dependability is required of all employees? Yes No
35. Do you understand that employment is contingent upon satisfactory education, prior employments and reference verification? Yes No
36. Do you further understand that willfully making false statements on this aplication will be sufficient cause for discharge? Yes No
37. Do you understand that we are an Equal Opportunity Employer as outline in federal and New York State laws against discrimination? Also, that no qualified person with a disability shall be sujected to discrimination in our employment process? Yes No
38. Do you understand that any offer of employment is contingent upon your providing proof of U.S. Citizenship or authorization to work in the U.S.? Yes No
39. We are committed to providing "loving care" to all clients and we require that all employees share this commitment. If employed by us, can you share this commitment? Yes No
We Are An Equal Opportunity Employer
I understand that all information concerning residents, clients, their doctors, and fellow employees is strictly confidential. I agree to honor the policy which states certain corporate and employee business is confidential. I hereby affirm the information provided in this application to be true and complete to the best of my knowledge.