Caire Home Healthcare

Employment Application

Note: You must fill out this form in one sitting and submit it as soon as you have it completed to avoid having to fill it out again. If you need to, gather your resume or other materials before you start, and refresh the page once when you are ready to begin. Required fields have a light yellow background. Please fill out all fields if possible. You must complete a background check form as well.

First Name:

Middle Name or Initial:

Last Name:

Address:

City:

State:

Zip:

SSN:

Date you are available to start:

Phone:

E-mail:

Position desired:

Salary desired:

Are you a U.S. Citizen?

If no, are you authorized to work in the US?

Have you ever worked for this company?

If yes, when?

Have you ever been convicted of a felony?

If yes, explain.

Education

High school:

Address:

Did you graduate?

Diploma?

From:

To:

College:

Address:

Did you graduate?

Degree?

From:

To:

Other:

Address:

Did you graduate?

Degree?

From:

To:

References

Please list three professional references.

First reference:

Full Name:

Company:

Relationship:

Phone:

Address:

Second reference:

Full Name:

Company:

Relationship:

Phone:

Address:

Third reference:

Full Name:

Company:

Relationship:

Phone:

Address:

Previous Employment

First job:

Company:

Address:

Phone:

Position:

From:

To:

Starting salary $

Ending salary $

Responsibilities:

Reason for leaving:

Supervisor:

May we contact your previous supervisor for a reference?

Second job:

Company:

Address:

Phone:

Position:

From:

To:

Starting salary $

Ending salary $

Responsibilities:

Reason for leaving:

Supervisor:

May we contact your previous supervisor for a reference?

Third job:

Company:

Address:

Phone:

Position:

From:

To:

Starting salary $

Ending salary $

Responsibilities:

Reason for leaving:

Supervisor:

May we contact your previous supervisor for a reference?

Military Service

Branch:

From:

To:

Rank at discharge:

Type of discharge:

If other than honorable, please explain.

Anything else you would like us to know:

Disclaimer and Signature

By entering my name in the SIGNATURE field provided below I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature:

Today's date:

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