Caregiver Application by QGbL6dj

VIEWS: 12 PAGES: 2

									                         QUALITY CARE 4 U

                   APPLICATION FOR INDEPENDENT CONTRACTOR

PERSONAL INFORMATION                                              DATE:_______________

Last Name: _______________________ First Name:_____________________________ M. I.:__________

Maiden Name: _______________________                   Date of Birth: _________________________

Home Phone [      ]______________ Work Phone [        ]______________ Cell # [   ]_________________

Address: _____________________ Apt. #______ City_________________ State__________ Zip_________

Social Security Number: ___________________________ Driver’s License #: ________________________

Date Available: ____________ Day and time available: M _____T______W_____ T_____ F___ S____ S____
Live-in
Are you employed now?           YES      NO
If so, may we contact your present employer?       YES           NO

Who referred you to this company? Newspaper   Friend Walk-In Website   Employment Agency Other:

                                         CURRENT & FORMER EMPLOYERS
 Name of Current Employer:                                         Phone: [  ]       ______
Address:                               City:             State:         Zip:   ________
Starting Date:               Leaving Date:                 Job Title:                ______
Hourly Starting Salary:                           Hourly Final Salary:               ______
Name of Supervisor:                               Title:                             ______
Description of work:                                                                 ______
________________________________________________________________________________________
Have you been disciplined during your employment?        YES           NO            ______
If YES, please explain:                                                              ______
_________________________________________________________________________________________
_________________________________________________________________________________________
                                                                                     ______
 Name of Former Employer:                                   Phone: [      ]          ______
Address:                               City:             State:         Zip:         ______
Starting Date:               Leaving Date:                 Job Title:                ______
Hourly Starting Salary:                           Hourly Final Salary:               ______
Name of Supervisor:                               Title:                             ______
Description of work:                                                                 ______
________________________________________________________________________________________
Have you been disciplined during your employment?        YES           NO            ______
If YES, please explain:                                                              ______
Reason for leaving?                                                                  ______
                                                                                     ______
________________________________________________________________________________________
 Name of Former Employer:                                   Phone: [      ]          ______
Address:                               City:             State:         Zip:         ______
Starting Date:               Leaving Date:                 Job Title:                ______
Hourly Starting Salary:                           Hourly Final Salary:               ______
Name of Supervisor:                               Title:                             ______
Description of work:                                                                 ______
________________________________________________________________________________________
QUALITY CARE 4 U                       EMPLOYMENT APPLICATION                                         PAGE            2
Have you been disciplined during your employment?                                 ______
                                                                                       YES                NO
If YES, please explain:                                                           ______
Reason for leaving?                                                               ______
                                                                                  ______
________________________________________________________________________________________
 Name of Former Employer:                                   Phone: [      ]       ______
Address:                               City:             State:         Zip:      ______
Starting Date:               Leaving Date:                 Job Title:             ______
Hourly Starting Salary:                           Hourly Final Salary:            ______
Name of Supervisor:                               Title:                          ______
Description of work:                                                              ______
________________________________________________________________________________________
Have you been disciplined during your employment?        YES           NO         ______
If YES, please explain:                                                           ______
Reason for leaving?                                                               ______
                                                                                  ______
________________________________________________________________________________________

REFERENCES: List 3 persons, (NOT) Employers and Relatives you have known at least 1 Year
 NAME                                 RELATIONSHIP TO YOU                                           PHONE #                   YRS. KNOWN
1.
2.
3.

HAVE YOU BEEN COVICTED OF A CRIME, OTHER THAN MINOR TRAFFIC VIOLATIONS IN
PENNYSYLVANIA? NO YES IF YES, EXPLAIN: _____________________________________________

HAVE YOU BEEN CONVICTED OF A CRIME, OTHER THAN MINOR
TRAFFIC VIOLATIONS IN ANY OTHER STATE? NO YES IF YES, EXPLAIN: ______________________

HAVE YOU EVER BEEN ACCUSED, ARRESTED, OR CONVICTED OF SEXUAL MOLESTATION IN PA?
NO YES     WHEN? ________________ WHERE? ____________________________________________
OTHER STATE? NO YES WHEN? _______________ WHERE? ________________________________

NOTE: CONVICTION OF A VIOLATION OF THE LAW IS NOT AN AUTOMATIC BAR
TO EMPLOYMENT. EACH CASE IS CONSIDERED ON ITS OWN MERIT.


APPLICANT AUTHORIZATION                              PLEASE READ CAREFULLY

“I certify that the facts contained in this application, and accompanying resume, if any, are true and complete to the best of
my knowledge. I understand that, if employed, falsified statements on this application will be grounds for termination from
Quality Care 4 U LLC.

I authorize a criminal background check as well as an investigation of all statements contained in this application
 regarding my school/work history as well as references to obtain information on their experiences with me. If
hired/contract acted, I agree to a criminal background check and to be finger-printed. Upon termination, I authorize
 the release of reference information to potential employers.”

DATE: ________________ APPLICANT SIGNATURE: ________________________________
QUALITY CARE 4 U IS AN EQUAL OPPORTUNITY EMPLOYER

All qualified candidates receive consideration for employment without regards to race, color, Religion, national origin, ethnicity, sex sexual
orientation, age, the presence of an Accommodatable medical condition or disability, veteran status, or other categories protected by law.

								
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