Private Care Associates

Today's Date
Name
First Middle Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell
Email

EMPLOYMENT BACKGROUND
List in order, most recent position first.
If presently employed, may we contact your employer for reference?
- Yes
- No
Firm Name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Type of Employment:
- Full-Time
- Part-Time
Starting Position
Supervisor
Duties and Responsibilities:
From Date
To Date
Starting Wage
Final Wage
Reason for Leaving:
Add another job Remove Job

Have you ever been convicted of a crime other than a minor traffic violation?
- Yes
- No
Please explain:
Do you currently have felony charges pending against you?
- Yes
- No
Please explain:
Have you ever been suspended or discharged from employment?
- Yes
- No
Please explain:
For licensed professionals, have you ever had your license suspended or revoked in ANY state?
- Yes
- No
Please explain:

Private Care Associates, Inc. is an equal opportunity employer and complies with all laws prohibiting discrimination on the basis of race, color, age, sex, national origin, religion, citizenship, handicap, weight or marital status.

I hereby authorize an investigation of my past employment; activities and statements contained in this application and release from all liability and responsibility all persons, companies or corporations supplying such information.

I understand that such information my include a record of disciplinary action assessed by previous employers, and hereby release such parties from any obligation to supply me with written notification of such disclosure

I certify that the above information about me is correct and understand that false information my be sufficient cause for termination.

I understand that my employment offer is conditional upon successful completion of a physical examination, which may include a drug screen, completion of employment eligibility verification, and upon receipt of satisfactory references.

I further declare that I am not using any illegal drugs and do not engage in improper self-medication.

I understand that if employed by Private Care Associates, Inc. I may be subject to medical evaluation to determine suitability to work in accordance with private duty policy and procedure.
I
understand that PCA is a Temporary Staffing Agency. PCA does not Guarantee Hours, Work Location and does not guarantee the shift flexibility (days, afternoon, nights).
Signature
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