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Application Form

For this type of Employment State Law Requires a Criminal Background Check as Condition of 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, medical condition, national origin or marital status. Company policy requires submittal to drug testing to detect the use of illegal drugs “prior to and during” employment.

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Address(Required)

Home Phone(Required)

City(Required)

Zip(Required)

Cell Phone(Required)

Social Security Number(Required)

Email(Required)

Other Names

Please list any other name(s) you have used (i.e. maiden and/or alias)

How did you hear about us?(Required)

Position applying for(Required)

Emergency Contact

Name(Required)

First Last

Phone(Required)

Address(Required)

Relationship

Transportation

You are required to travel to a client’s home.

Do you have a dependable transportation?(Required)

Yes

Make

Model

License Plate No.

Driver's License No.

Auto Insurance Policy No.

Insurance Company Name

Hours of Availability

In order to better process your application, we need to determine your exact availability. Please consider all events such as school, childcare, religious activities, other employment duties, etc. before determining your hours of availability. If you are the selected candidate, the availability noted below will determine your work schedule. NOTE: If you are not available for work during the hours specified below, it may result in less work hours and/or termination of employment.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Notes

Are you available to work night shift (s)?

Yes

If yes, what nights

Education

High School(Required)

City/State(Required)

Highest Level Completed(Required)

Course of Study(Required)

College(Required)

City/State(Required)

Highest Level Completed(Required)

Course of Study(Required)

Other(Required)

City/State(Required)

Highest Level Completed(Required)

Course of Study(Required)

Degrees/Certificates:(Required)

Registered C.N.A.?(Required)

Yes

Certification No.:

State Registry

If you were a C.N.A., when/why did your certification expire?

Special skills or courses for position applied for:

Experience

Please provide any training or experience working with the elderly:(Required)

What do you like most about working with the elderly?(Required)

What do you like least about working with the elderly?(Required)

Employment History

Provide work history for at least five (5) years; tell us about your work history. Use a separate sheet if additional space is needed. Please attach a resume if applicable. List your most recent employer first.

May we contact your recent employer?(Required)

Yes

Company

From

Job Title

Reason Left

Job Duties

Supervisor:

Phone No

Company

From

Job Title

Reason Left

Job Duties

Supervisor:

Phone No

Company

From

Job Title

Reason Left

Job Duties

Supervisor:

Phone No

Company

From

Job Title

Reason Left

Job Duties

Supervisor:

Phone No

Company

From

Job Title

Reason Left

Job Duties

Supervisor:

Phone No

Legal History

For this type of Employment State Law Requires a Criminal Background Check as Condition of Employment. A Personal Services Agency SHALL NOT EMPLOY an individual to provide direct services to a client if the individual: a) Has been convicted of a crime defined by KRS216.710(3) - "CRIME" means a conviction of or a plea of guilty to a felony offense related to theft; abuse or sale of illegal drugs; abuse, neglect, or exploitation of an adult or child; or the commission of a sex crime. Conviction of or a plea of guilty to an offense committed outside the Commonwealth of Kentucky is a crime if the offense would have been a felony if committed in Kentucky; b) Appears on the nurse aide and home health aide abuse registry; c) Test positive for the presence of an illegal drug. COMPANY POLICY STATES: NO MISDEMEANOR DRUG OR THEFT RELATED CHARGES OF ANY TYPE ARE ALLOWED ON A CRIMINAL BACKGROUND CHECK.

Have you ever been acquitted or convicted of a Felony?(Required)

Yes

Have you ever been acquitted or convicted of a Misdemeanor. other than a minor traffic violation?(Required)

Yes

If yes, please provide details:

Professional References

Name

First Last

Address

Relationship/Years Known

Phone

Name

First Last

Address

Relationship/Years Known

Phone

Name

First Last

Address

Relationship/Years Known

Phone

Personal References

Name

First Last

Address

Relationship/Years Known

Phone Number

Name

First Last

Address

Relationship/Years Known

Phone Number

Name

First Last

Address

Relationship/Years Known

Phone Number

Certification and Release(Required)

I certify that I have read and understand the application note on page one (1) of this form and that the answers given by me to the foregoing questions and 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 consumer reporting bureaus, to verify any information including, but not limited to: criminal background history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. Company policy requires submittal to drug testing to detect the use of illegal drugs prior to and during employment. Please sign below to verify that you have read and fully understand TTSS application.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Apply Today

Apply Today

Application Form

Emergency Contact

Transportation

Hours of Availability

Education

Experience

Employment History

Legal History

Professional References

Personal References

Contact Information

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