Employment Application Caregivers Health Network is an Equal Opportunity Employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, disability, age, national origin, ancestry or any other classification protected by law. Please complete all of the fields below by entering or selecting the requested information. In large fields, save time and use the 'copy' and 'paste' function from your resume.  Name:          First Name    MI   Last Name Date Available?:       mm/dd/yyyy Home Phone:    xxx-xxx-xxxx e-mail Address: Re-enter e-mail Adress        Full Address:       Street/PO Box   ,    City,  State  Zip Code SSN:       xxx-xx-xxxx Are you 18 years  or older?    Yes    No Are you a U.S. Citizen or an alien authorized to work in the U.S?   Yes    No Position Desired:    RN  LPN  CNA  PCA HMK  Office Days I am available-  Specify Days & Hours:    MON  TUE  WED  THU FRI  SAT SUN Hours I am available:     Who referred you:    Agency  Newspaper  Employee   Radio Other Have you ever been convicted of a felony or pled guilty, or no contest to a crime?  Yes  No (Conviction of a crime does not necessarily disqualify the applicant from employment consideration).  If you responded "YES" to either question, please explain.    Have you read a job description or had the requirements of the job explained to you? Yes  No Do you understand the requirements?  Yes  No Do you have any relatives currently employed by Caregivers? Yes  No Have you previously worked at Caregivers? Yes  No Do you have adequate transportation? Yes  No Do you have automobile liability insurance? Yes  No   Education Record  School:       Name of School   City   Did you graduate? Yes  No     Major Course/Subject Highest Degree Earned:    High School:    College:    Outside Activities:         Record of Employment Beginning with your present or most recent position, list the last four jobs you have held, including a summary of experience, etc. (indicate military experience if job related). If you have a résumé, please attach to application with the button at the bottom of the page. Current Employer:       Company Name Type Of Business      Address Phone Dates of Employment:   mm/dd/yyyy       Beginning Date Ending Date Starting Title:    Last Title:    Starting Salary:        Final Salary:  Name of Supervisor:    Reason for leaving:    Brief description of duties:     Number of hours  worked per  week:    Previous Employer 2:       Company Name Type Of Business      Address Phone Dates of Employment:   mm/dd/yyyy       Beginning Date Ending Date Starting Title:    Last Title:    Starting Salary:        Final Salary:  Name of Supervisor:    Reason for leaving:    Brief description of duties:     Number of hours  worked per  week:    Previous Employer 3:       Company Name Type Of Business      Address Phone Dates of Employment:   mm/dd/yyyy       Beginning Date Ending Date Starting Title:    Last Title:    Starting Salary:        Final Salary:  Name of Supervisor:    Reason for leaving:    Brief description of duties:     Number of hours  worked per  week:    Previous Employer 4:       Company Name Type Of Business      Address Phone Dates of Employment:   mm/dd/yyyy       Beginning Date Ending Date Starting Title:    Last Title:    Starting Salary:        Final Salary:  Name of Supervisor:    Reason for leaving:    Brief description of duties:     Number of hours  worked per  week:    Summarize other prior, relevant experience, and fill in periods of unemployment or periods not accounted for above.         Personal References 1st Reference:       First Name   Last Name      Address    Phone 2nd Reference:       First Name   Last Name      Address    Phone 3rd Reference:       First Name   Last Name      Address    Phone I hereby certify that the above information is correct and complete to the best of my knowledge. I make this statement understanding that any false or misleading statement or omission of facts may result in dismissal from consideration or employment. I authorize Caregivers Health Network, Inc. to verify any of the information I have submitted in this application. I Agree to these terms Attach Resume Here (will browse your pc for the file)