* = Required Information
AN EQUAL OPPORTUNITY EMPLOYER
PERSONAL:
DATE:
Social Security No.
Name
Last * First * Middle
Current Address
Street City State Zip
Home Telephone Cell Email Address *
If under 18, please list age
Can you submit verification of your legal right to work in the U.S?
Position:
Private Duty Sitting:
Desired Salary:
Date you can start:
How many hours can you work weekly?
Can you work nights?
Yes No
Employment desired:
FULL-TIME ONLY PART-TIME ONLY NO PREFERENCE
Availability:
No Pref Mon Tue Wed
Thu Fri Sat Sun
Live In
Do you have valid driver's licence?    
Yes No
Do you have reliable transportation to work assignments?    
Yes No
Can you provide proof of automobile insurance?                    
Yes No
Driver's Licence Number
State of issue
Operator
Commercial (CDL)
Chauffeur
Expiration Date
Have you had any accidents during the past three years?    
Yes No
If so how many?
Have you had any moving violations in the past three years?
Yes No
If so how many?
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
Yes No
If yes,explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed and type(s), of rehabilitation.
Military
Have you ever been in the armed forces?
Yes No
Are you now a member of the National Guard?
Yes No
Specialty Date Entered Discharge Date
Work History
Please list your work experience for the past five years beginning with your most recent job held. If you were self employed, give the final name . Attach the additional sheets if necessary.
Name of employer
Address
City
State
Zipcode
Phone number
Name of Supervisor
Employment dates:    From To
Pay or Salary:    From To
Last job title:
Reason for leaving (be specific)
Lists the jobs held; duties performed skills used or learned, advancements or promotions while you worked at this company.
May we contact?
Yes No
Name of employer
Address
City
State
Zipcode
Name of Supervisor
Employment dates:    From To
Pay or Salary:    From To
Last job title:
Reason for leaving (be specific)
Lists the jobs held; duties performed skills used or learned, advancements or promotions while you worked at this company.
May we contact?
Yes No
Name of employer
Address
City
State
Zipcode
Name of Supervisor
Employment dates:    From To
Pay or Salary:    From To
Last job title:
Reason for leaving (be specific)
Lists the jobs held; duties performed skills used or learned, advancements or promotions while you worked at this company.
May we contact?
Yes No
Education:
Type of School Name of School Location Years Completed Degree Earned
High School
College
Vocational School
REFERENCES:
Please list three business refereces taht have knowledge of your work history.
Name
Company
Telephone
Position
Address
Name
Company
Telephone
Position
Address
Name
Company
Telephone
Position
Address
Applicants Authorization (please read carefully)
I certify that the facts contain on this application are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be grounds for dismissal or prosecution. I authorize investigation of all statements contained herein and the references and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release Family Care Home Health from all liabilities for any damage that may result form utilization of suxh information.