Care For Life Inc. Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - U.S. Citizen

If not U.S. citizen, do you have proof of legal right to work? (required)

Yes No

Section 2 - Vehicle - Transportation

Do you have a reliable vehicle or means for transportation (required)

Section 3 - Education - Skills

Do you have a current CNA license (required)

Yes No

Do you have an expired CNA license (required)

Yes No

List any other licenses

Work or Training in HH, Hospice, AL, Skilled Care (required)

Section 4 - Work History 1

Name of Company (required)

Sill currently employed here (required)

Yes No

City (required)

State (required)

Reason for Leaving or Still Actively Employed (required)

Describe your role (required)

Section 5 - Referred By

Who or How were you referred to us (required)

Section 6 - References 1

Name (required)

Address

Telephone (required)

(Numeric Answer Only)

Company (required)

Title (required)

Section 7 - References 2

Name (required)

Address

Telephone (required)

(Numeric Answer Only)

Company (required)

Title (required)

Section 8 - Other

Have you ever been arrested for, convicted of, pleade guilty or pleas nolo contendere (no Contest) to a criminal offense other that a minor traffic ticket? (required)

Yes No

Are you willing to work in homes with animals (cats, dogs)? (required)

Yes No

Are you able to perform the duties of this job without special accomodations? (required)

Yes No

What shifts and days of the week are you available? (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

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