Dedicated Care Living | Employment

THIS ONLINE FORM IS SAFE & SECURE

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with Dedicated Care Living, Inc. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

Personal Information

First Name *

Middle Name

Last Name *

Current Address

Street Address line 1 *

Street Address Line 2

City *

State/Province *

Postal/Zip Code *

County *

How long have you lived at this address? *

Contact Information

Home Phone

Cell Phone *

Email Address *

Person name, In case of emergency *

Contact number, In case of emergency *

Have you applied with Dedicated Care Living before? *

Yes

Are you legally authorized to work in the US? *

Yes

How did you here from us? *

Have you ever been convicted for a crime? If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation ( A conviction will not necessarily result in the denial of employment ): *

Education Information

Name Of High School Attended *

High School address *

Number Of Years Completed *

Name Of College Attended *

College address *

Number Of Years Completed *

List Any Certificates, Degrees and/or Awards You Have Received. *

Driving Information

Do you have driver's license? *

Yes

Do you have car? If No, How Would You Get To Work? *

Yes

Do You Have Auto Insurance ? *

Yes

Have You Had Any Accidents In The Last 3 Years? If Yes, Please Explain Each Incident. * *

Work Experience

Employer First Name *

Employer Middle Name *

Employer Last Name *

Employer Phone number *

Years known *

Street Address line 1 *

Street Address Line 2

City *

State/Province *

Postal/Zip Code *

County *

Name Of Last Supervisor? *

Employment Dates: From When To When Did You Work Here? *

Your Last Job Title There? *

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here: *

Reason For Leaving? *

May We Contact This Employer? If No, Please Explain Why, and Provide Another Work Reference. *

When Are You Available To Start Working With Us? *

How Many Hours Can You Work Each Week? *

Employment Desired? *

Please List The Days & Times That You Are Available To Work With Us? *

COMPANIONSHIP EXPERIENCE *

MEAL PREPARATION *

LIGHT HOUSEKEEPING *

BATHING / SHOWERING *

DRESSING / GROOMING *

TRANSFERRING *

INCONTINENCE CARE *

DEMENTIA ALZHEIMER'S CARE *

HOSPICE CARE *

Personal Reference Information

List two personal references. DO NOT LIST relatives or previous supervisors.

REFERENCE, Provide Name, Phone #, Address & Your Acquaintance With This Reference ( Friend, Co-Worker, etc ) *

REFERENCE, Provide Name, Phone #, Address & Your Acquaintance With This Reference ( Friend, Co-Worker, etc )

Upload certificate if you have any:

Upload Your Resume Here:

I certify that the facts set forth for employment are true and complete to the best of my knowledge. i understand that if employed, false statements on this application shall be considered sufficient cause of dismissal. you are hereby authorized to make investigation queries of my personal references. *

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