Employment Opportunities Form

Date

Position Applying for *

Name (Last Name, First Name, MI)*

Social Security #

Email *

Telephone Number (Day) *

Telephone Number (Evening)

Address Information

Address *

City *

State

Zip

Education

Name and Address of High School*

City *

State

Diploma or High School Equivalency

Yes

No

Date Diploma or GED Received

College or University (Undergraduate)

Years Completed

Major

College or University (Undergraduate)

Years Completed

Major

Degrees Received

Other Education

Special Skills or Training

License and Certifications (Include CPR and First Aid)

Type

State Issued

Date Expires

Number

Type

State Issued

Date Expires

Number

Employment History

Employer's Name and Address

City

State

Zip

Phone Number

Date of Employment

Current Job Title

Reason for Leaving

Supervisor's Name and Telephone No.

Duties/Responsibilities

Employer's Name and Address

City

State

Zip

Phone Number

Date of Employment

Current Job Title

Reason for Leaving

Supervisor's Name and Telephone No.

Duties/Responsibilities

Employer's Name and Address

City

State

Zip

Phone Number

Date of Employment

Current Job Title

Reason for Leaving

Supervisor's Name and Telephone No.

Duties/Responsibilities

If currently employed, may we contact employer?

Yes

No

References (List three references - non-relatives)

Name

Address

Phone Number

Relationship

Name

Address

Phone Number

Relationship

Name

Address

Phone Number

Relationship

Describe your recent experience in working with the sick and/or elderly

Other Information

U.S Citizen

Yes

No

Eligible for Employment in U.S

Yes

No

Available for Shift Work

Yes

No

Convicted of Crime (Other than minor traffic violation)

Yes

No

Are you at least 18 years of age?

Yes

No

Military Service?

Yes

No

Branch & Serial #

Rank at discharge

Please explain circumstances surrounding any convictions of felony or misdemeanor, including dates and sentence(s)

Days Available for work (Please indicate AM, PM or Any)
Mon Tues Wed
Thurs Fri Sat Sun

When can you start?

Desired Wages

Do you have any friends or relatives currently working for KG40 Inc./CarolKay HealthCare Services?

Yes

No

Name of Friend/Relative

Relationship

Acknowledgement

I declare that all information contained in this employment application is true, complete and accurate to the best of my knowledge and understand that any false statement or misrepresentation may disqualify me from employment or may be grounds for discharge if later discovered.
I consent to all medical examinations and drug screenings by CarolKay HealthCare Services and understand that any offer of employment is contingent upon the results of a pre-employment medical examination, drug screening; and criminal and child protective services clearances. All results of medical examinations and drug screenings are the property of CarolKay HealthCare Services.
I authorize my former employer to release all information concerning my employment. I further authorize the release of any such information during and after my employment without prior notification. This authorization releases the aforementioned parties and CarolKay HealthCare Services from any liability for the collection and reporting of this information.
I understand that if I am employed by CarolKay HealthCare Services my employment is "at will" and may be terminated by me or by CarolKay HealthCare Services at any time with or without cause, for any reason or no reason. The Program Director of CarolKay HealthCare Services is the only authority who can enter into an agreement contrary to the foregoing and any such agreement must be in writing and signed by both the Program Director and me.

Applicant Name *

Date

CarolKay HealthCare Services is an equal opportunity employer and does not discriminate on the basis of age, sex, race, color, marital status, religion, sexual orientation, national origin, disability, military status, or any other protected category.