PERSONAL INFORMATION
Emergency Contact
Local
Out-of-Area
EDUCATION
Formal
Informal
Work Limitations
List any work limitations that you may have and briefly describe:
WORK AVAILABILITY
Indicate Days and List Hours Available for Work:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
CLIENT TYPES AND WORK DUTIES
TRANSPORTATION
Transporting Clients
ABUSE INVESTIGATION
JOB REFERENCE
Work Related #1 (Last Position)
Work Related #2 (2nd Last Position)
Work Related #3 (3rd Last Position)
Personal #1
Personal #2
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to NANA'S 24/7 HOME CARE & COMPANION AGENCY, LLC and I hereby release and discharge any of the above and NANA'S 24/7 HOME CARE & COMPANION AGENCY, LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.
I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test, if part of the Agency's pre-employment policy.
I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.
Clear
PRE-EMPLOYMENT AUTHORIZATION
I, *, understand that as part of the employment process, NANA'S 24/7 HOME CARE & COMPANION AGENCY, LLC needs to complete a background check on me regarding:
*
List any other cities, states and dates of residency during last 10 years
I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to NANA'S 24/7 HOME CARE & COMPANION AGENCY, LLC or its authorized agent(s).
I also understand that I do not have to give authorization for a background check, but if I don't give permission, my employment application will not be processed further.
I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
I further authorize that a photocopy of this authorization may be considered as valid as the original.
I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with NANA'S 24/7 HOME CARE & COMPANION AGENCY, LLC is contingent upon successful completion of a background check.
SMS OPT-IN
Please use this form to provide your consent to receive occasional text messages from Nana's 24/7 Home Care & Companion Agency, LLC, on your personal device. Text messages are optional, and may include:
I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.
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