Employment

Our Caregivers

Submitted by admin on Mon, 07/27/2009 - 12:39am

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Sitters Etc. Application for Employment
Equal Opportunity Employer

First Name:

Last Name:

Middle Initial:

Address:

City:

State/Province:

Zip/Postal Code:

Home Phone:

Mobile/Pager:

E-Mail:

Former Employers

Company Name:

From Date:

To Date:

Phone Number:

Position/Reason for Leaving:

Rate of Pay:

Former Employers 2

Company Name:

From Date:

To Date:

Phone Number:

Position/Reason for Leaving:

Rate of Pay:

Former Employers 3

Company Name:

From Date:

To Date:

Phone Number:

Position/Reason for Leaving:

Rate of Pay:

Education:

List degrees, certifications, special skills, caregiving experience, etc.

References

List below the names of three persons not related to you, and known at least a year

First Reference

Name:

Phone:

Years Known:

Second Reference

Name:

Phone:

Years Known:

Third Reference

Name:

Phone:

Years Known:

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

Digital Signature:

Date:

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