Careers Form

Full Name *

Address *

City *

State

Zip *

Phone Day *

Phone Evening

Email Address *

Social Security Number *

Do you have a valid Driver's License?

Yes

No

Drivers License Number

Are you over 18? *

Yes

No

What license do you currently hold?

HHA

RN

LPN

None

Do you have reliable transportation to get to work?

Yes

No

What shifts are you available for?

Days

Afternoons

Evenings/Nights

Any

Is there a specific time to your availability?

Yes

No

What position(s) are you applying for?

Please provide the times

How many hours per week?

Other Certifications

Name of employer *

From *

To *

Salary/Hourly Wage *

Position *

Reason for Leaving *

Can we contact your supervisor? *

Yes

No

Supervisor Name *

Supervisor Number *

Name of employer

From

To

Salary

Position

Reason for Leaving

Can we contact your supervisor?

Yes

No

Supervisor Name

Supervisor Number

Name of employer

From

To

Salary

Position

Reason for Leaving

Can we contact your supervisor?

Yes

No

Supervisor Name

Supervisor Number

High School

Date graduated

College

Date graduated

Degree

Have you ever worked for us?

Yes

No

Upload Document file here (Such as: Copy of your Drivers License,High School Diploma GED, Transcripts, Social Security Card, CPR First Aid Certification)

Reason for leaving?

How did you hear about us?

Name

Address

Phone

Years Acquainted

Name

Address

Phone

Years Acquainted

Name

Address

Phone

Years Acquainted

Attach Resume

Have you ever been convicted of a Felony? *

Yes

No

If yes, please explain

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. *

I understand that consideration for employment is contingent on the results of my reference, a background check and possible drug and alcohol screening. Therefore, I hereby authorize Quality Comfort Living & Services and/or its affiliates to investigate the truthfulness of all statements made in this application. *

Date