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Services
Private Duty Nursing
Companion Care
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Housekeeping
Medicaid Waiver Programs
Blog
Service Areas
Careers
Training
Contact
Message Us
Careers Application Form
"
*
" indicates required fields
Step
1
of
5
20%
Position Applied For
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Today’s Date
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MM slash DD slash YYYY
Date Available For Work
*
MM slash DD slash YYYY
Name
*
First
Middle
Last
Date of Birth
*
MM slash DD slash YYYY
Current Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Driver’s License Number
*
Issuing State
*
Previous Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Social Security Number
Alternate Number
*
Telephone Number
*
Email Address
*
Identify where you learned about employment opportunities with precious care
*
Are you legally eligible to work in the united states?
*
Yes
No
(In accordance with the Immigration report and Control Act of 1986, you have three (3) days after hiring to produce documents to verify U.S. citizenship and/or authorization to work in the United States, and must sign a Form -9).
Are you at least 18 years of age?
*
Yes
No
(if no, you may be required to provide a work authorization)
Have you ever applied to precious care agency before?
*
Yes
No
(If yes, please give date)
Have you ever been convicted of a felony in the past 7 years?
*
Yes
No
(a conviction will not necessarily disqualify you from consideration)
If yes, please explain:
Check days) and write the time(s) you are available to work:
*
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Are you available to work overtime when necessary?
*
Yes
No
EMPLOYMENT HISTORY
Please start with most recent employer. Use additional sheet if necessary.
Current Employer
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Supervisor Name/Title
*
Address
(No. Street) (City, State, Zip)
Position Held
*
Phone #
Ending Salary
Responsibilities
*
Reason For Leaving
*
May we contact your current employer?
*
Yes
No
If you have concerns about having your current employer contacted, please communicate those concerns to the person who conducts your initial interview to determine what, if any, alternatives exist.
Current Employer
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Supervisor Name/Title
*
Address
(No. Street) (City, State, Zip)
Position Held
*
Phone #
Ending Salary
Responsibilities
*
Reason For Leaving
*
Current Employer
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Supervisor Name/Title
*
Address
(No. Street) (City, State, Zip)
Position Held
*
Phone #
Ending Salary
Responsibilities
*
Reason For Leaving
*
List any special training (including use of medical equipment/computer skills), certificates, licenses, and other skills which You have received, which relate to the position you are applying for:
*
Provide any other information that you feel will help us in considering your application for employment:
*
EDUCATION AND TRAINING:
HIGH SCHOOL
NAME
ADDRESS
Course of Study
Diploma/Degree Awarded
Year Graduated
COLLEGE
NAME
ADDRESS
Course of Study
Diploma/Degree Awarded
Year Graduated
TRADE/BUSINESS SCHOOL
NAME
ADDRESS
Course of Study
Diploma/Degree Awarded
Year Graduated
REFERENCES
List three persons not related to you whom you have known for at least three (3) years.
Name
*
First
Company Name
*
Company Address
Phone Number
Professional Relationship
Years Known
Name
*
First
Company Name
*
Company Address
Phone Number
Professional Relationship
Years Known
Name
*
First
Company Name
*
Company Address
Phone Number
Professional Relationship
Years Known
EMERGENCY CONTACT
Person to be notified in case of accident or emergency.
Name
First
Relationship
Address
Street Address
Home Phone
Work Phone
Cell Phone
Email
APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION
Please read carefully before signing
INITIAL
*
First
I understand that this application is considered current for six (6) months for the position specified on this application. If I wish to be considered for employment after this time period I must complete and submit a new application.
INITIAL
*
First
I certify that all statements (verbal and written) made on any and all material collected during the hiring process are true, complete and accurate, and I understand that misrepresentation or omission of facts called for in the employment application, resume, interview process or other application material may prohibit consideration for employment at Precious Care, and is cause for immediate termination if employed.
INITIAL
*
First
I understand that a comprehensive background investigation may be conducted as part of the employment process. I hereby authorize any and all schools, former employers, references, and any others who have information about me to provide such information to Precious Care. I understand that all offers of employment are contingent upon Precious Care’s satisfaction with the results of the background investigation and reference checks.
INITIAL
*
First
I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Precious Care, such employment is “at-will.” “At-will” means that employment with Precious Care is for no specified duration and may be terminated by either Precious Care or myself at any time, with or without cause or notice.
INITIAL
*
First
In consideration for employment with Precious Care, if employed, I agree to comply with the rules, regulations, policies and procedures of Precious Care at all times and understand that such compliance is a condition of employment. I understand that due to the nature of Precious Care’s business, attendance and punctuality are considered essential requirements of work, and that poor attendance or tardiness may result in disciplinary action.
Precious Care is an equal opportunity employer and affords equal opportunity to all applicants for positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.
Thank you for expressing an interest in employment with Precious Care.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.
Print Name
*
First
Signature
*
Date
*
MM slash DD slash YYYY
VOLUNTARY SELF-IDENTIFICATION FORM
Government agencies may require reporting on the status of applicants. This data will not be used in the selection process and will be kept confidential (separate from the application form). Submission of such data is voluntary; choosing not to supply this information will not jeopardize or adversely affect any consideration you may receive for employment or later advancement in employment.
Name
*
First
Date
MM slash DD slash YYYY
Gender
*
Male
Female
Position Applied For
Please select one of the following Equal Employment Opportunity Identification Group:
American Indian or Alaskan Native
- A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian
- A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American
- A person having origins in any of the Black racial groups of Africa. Terms such as "Haitian" can be used in addition to "Black or African American."
Native Hawaiian or Other Pacific Islander
- A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White
- A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic or Latino (All races)
- A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Hispanic or Latino (White race only)
- A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of the White race.
Hispanic or Latino (all other races)
- A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of any race other than White.
For Human Resources: Race missing or unknown
- Applies to applicants only when a resume or application that is screened is received without any racial or ethnic identification and no further contact is made with the applicant.
Veteran
*
Yes
No
Phone
This field is for validation purposes and should be left unchanged.
Quick Inquiry
"
*
" indicates required fields
Name
*
First
Last
Email Address
*
Phone Number
Questions
*
Comments
This field is for validation purposes and should be left unchanged.
