Employment Full Name Email Address Physical Address City, State, Zip Phone Number* Are you over 18 years of age? YesNo Are you legally eligible to work in the United States? YesNo Please list all days and hours you are available to work. How flexible are you to cover shifts and substitute for teammates, outside of your regular work schedule?Highly FlexibleSomewhat FlexibleRarely FlexibleNever Flexible Do you have reliable transportation? YesNo Our night shifts are awake shifts. If applying for a night shift, you foresee any difficulty remaining awake and alert for the entire shift?YesNoN/A Date Available to Start Expected Salary? This position requires working some holidays and may require overtime, weekend work, and staying on shift until your relief arrives. Do you foresee any problems fulfilling these requirements? YesNo If “Yes”, please explain. Are you able to work the following shifts? Days: 7am – 7pm YesNo Swings: 3pm – 11pm YesNo NOC: 7pm – 7am YesNo PRN YesNo If you have any plans/appointments in the next three months that would conflict with your work schedule, please provide important information. Employment History Are you currently employed? YesNo Please list present and past employment starting with your most recent employer: 1. Employer/Company Name Dates Employed Supervisor’s Name Supervisor’s Contact Info Can we contact this employer?YesNo 2. Employer/Company Name Dates Employed Supervisor’s Name Supervisor’s Contact Info Can we contact this employer?YesNo 3. Employer/Company Name Dates Employed Supervisor’s Name Supervisor’s Contact Info Can we contact this employer?YesNo Education Please list present and past education starting with the most recent school: 1. School Name Field of Study Certification or Degree Earned Year of Completion 2. School Name Field of Study Certification or Degree Earned Year of Completion 3. School Name Field of Study Certification or Degree Earned Year of Completion Skills & Abilities Are you restricted from lifting specific weights?YesNo Have you dealt with incontinence (both bowel and bladder) and used incontinence products on any of your previous jobs?YesNo This job requires you to transfer residents from bed to wheelchair and from wheelchair to bed or toilet or chair. Do you have any physical limitations that would prohibit you from task?YesNo Is there any phase of housekeeping that you cannot do or are unwilling to do?YesNo If “Yes”, please explain. How would you describe your housekeeping skills (laundry, cleaning bathrooms, floors, etc.)? How would you describe your skills in preparing meals/cooking? What other skills/abilities do you have that pertain to this position? References 1.Name Email Relation Phone Number* 2.Name Email Relation Phone Number* 3.Name Email Relation Phone Number* Employee Credentials Check the boxes of your current credentials:CNA LicenseHCA LicenseCPR CardFirst Aid CardBackground CheckHIV/AIDS Certificate2 Step Tb (step 1 within 3 days of hire)Fingerprint Check (within 7 days of hire)Food Handler’s CardNurse Delegation CertificateDiabetic Delegation CertificateDementia CertificateMental Health Certificate What else would you like us to know about yourself? To the best of my knowledge, the information I have provided in this application is true and accurate. I understand that if I am offered a job with your company, accept it, and later it is determined that my answers to any of the above questions are not truthful; I may be dismissed from employement. Electronic Signature * Date of Signature * How do you hear about us:CraigslistZip RecruiterIndeedTacoma WeeklyFriend / FamilyOther If other, please specify Email Please upload your resume
