EMPLOYMENT APPLICATION, PART ONE
Phone:
Date:
We are located in Western Howard County, where do you live?
Do you have a car that can take you back and forth to work?" Yes No
Are you looking for full or part time? Full Time Part Time Either
Have you ever been charged with or convicted of a crime? If yes, please explain: Yes No Explain: (Include dates, circumstances, and outcome):
Do you have CNA or caregiver experience? If yes, please explain: Yes No Explain:
Are you meds trained? Yes No
Where have you worked?
Are you currently working? Yes No
If yes, where are you currently working?
What was your last job?
At your last job how many times were you late for work?
How is your health? Any health problems?
Any pre-existing injuries or conditions that would prevent you from walking steps or moving and transferring residents?
How free is your schedule for work? What current commitments would prevent you from being at work?
Do you have any personal commitments that would prevent you from coming to work? Do you have any family commitments that would prevent you from being to work early in the morning?
How do you feel about a split shift? (Ex. 7 a.m. to 1 p.m. then come back and work 4 p.m. to 8 p.m.)
How do you feel about working weekends? Saturday
Sunday
To submit this form, please enter the characters you see in the image:
Job Description:
Dressing, Bathing, feeding residents Cleaning and tidying rooms Adminstering medications if applicable Meal preparation Resident laundry, folding clothes Coordinating activities **This is not a COMPLETE job description, just a brief description, and there will be other duties as assigned.**