(267) 475-5995 info@lovingarmseldercare.com PO Box 2082 Warminster PA 18974 Application for Employment Date:  INSTRUCTIONS: Please read carefully. Every item on this form must be answered to the best of your ability. Please print and use a pen. Your qualifications will be carefully reviewed and you will be given thorough consideration for any suitable opening. Upon employment, this application will become part of your personnel record with Loving Arms Elder Care Corporation. Keep this in mind as you complete it. NOTE: Pennsylvania is an “At-Will State” meaning that the employer or  employee can terminate employment at any time and no reason for termination is needed by either party. You are not required to supply any information that is prohibited by federal, state or local law. Loving Arms Elder Care Corporation des not discriminate on the basis of race, color, religion, sex, national origin, citizenship, age, marital status or disability. You may request assistance in completing this application.   Last Name: MI: First Name:     Phone Number:     Address: Address: Mailing Address: (if different from above) Address: City: State:   Zip: Emergency contact:   Relation: Phone Number:   Have you ever worked for or applied for work with Loving Arms Elder Care? Yes  No Have you had any experience related to caregiving? Yes  No Nursing  Home  Family  Friend Other     Are you currently a CNA? Yes  No   (Certification is not required for employment) Do you have any other certifications or licenses? Yes  No   If so, please list them in the space provided below. Type of employment sought:  Reg. Full-time  Reg. Part-time  Temporary  As Needed When are you available for work?  Days  Nights  Weekends  Holidays Indicate hours you are available to work on the following days: Monday Tuesday Wednesday Thursday Friday Saturday Sunday to to to to to to to Are you available for live-ins?  Yes  No   If so, what days?   How did you hear about Loving Arms Elder Care? Have you ever been convicted of a crime other than a minor traffic violation? Yes  No   If yes, please explain       EMPLOYMENT HISTORY: Please list ALL PLACES OF EMPLOYMENT in chronological order, beginning with your current or most recent employer. Please request another reference page if needed. Job Title Employer City, State, Zip Phone Number Supervisor Dates Employed Reason for Leaving Job Title Employer City, State, Zip Phone Number Supervisor Dates Employed Reason for Leaving   Job Title Employer City, State, Zip Phone Number Supervisor Dates Employed Reason for Leaving Job Title Employer City, State, Zip Phone Number Supervisor Dates Employed Reason for Leaving Job Title Employer City, State, Zip Phone Number Supervisor Dates Employed Reason for Leaving PERSONAL REFERENCES 1. Name Phone Number   2. Name Phone Number   3. Name Phone Number   I certify that all information is true and correct to the best of my knowledge and give Loving Arms Elder Care permission to check all previous places of employment and references listed above. Signature Date

Loving Arms Elder Care • P.O. Box 2082 • Warminster PA 18974 • (267) 475-5995
 
Website powered by: Peregrine Associates