* FULL APPLICATION FORM

Personal Information

Physical Record

Vaccination Policy Acknowledgement

Education

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Employment History

List the last five years employment history, starting with the most recent employer.
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To be completed by Previous Employer

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Professional References

General Information

Physical Requirements

Mental Requirements

Credential/Specialized Skills & Qualifications/Equipment Operated

CREDENTIALS

SPECIALIZED SKILLS & QUALIFICATIONS


EQUIPMENT OPERATED

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I Certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GOUNDS FOR DISMISSAL.

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

APPLICANT REFERENCE CHECK

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
TO BE FILLED OUT BY APPLICANT:
TO BE COMPLETED BY PREVIOUS EMPLOYER:
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APPLICANT REFERENCE CHECK

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
TO BE FILLED OUT BY APPLICANT:
TO BE COMPLETED BY PREVIOUS EMPLOYER:
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APPLICANT REFERENCE CHECK (3)

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
TO BE FILLED OUT BY APPLICANT:
TO BE COMPLETED BY PREVIOUS EMPLOYER:
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EMPLOYEE EMERGENCY CONTACT INFORMATION

IN CASE OF EMERGENCY, PLEASE CONTACT:
Please notify this Agency immediately if any of the emergency contact information Changes.

BACKGROUND CHECK AUTHORIZATION

APPLICANT Complete the following information as accurately as possible. (Please Print Clearly).
ADDRESSES (List past seven years beginning with your current address. Include street, city, state, zip code, county and dates of residence. Attach additional sheet, if necessary.)
ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

*This information (Birth date and SSN) will be used for background screening purposes only and will not be taken into consideration in making any employment decisions.

EMPLOYEE AVAILABILITY

Please provide the following information on your availability to work for Crossing Care, LLC

Please Check (✓) the Day and Time of Week You Are Available

SUN MON TUE WED THUR FRI SAT
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Overnight

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