EmailMe Form - Canton - Caregiver Application

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Personal Information

Phone Number *

### - ### - ####

Email *

Are you eligible to work in the United States? *

Yes

No

If you are under age 18, do you have an employment/age certificate? *

Yes

No

If yes, please explain:

POSITION/AVAILABILITY:

Position Applied For (Non-Medical Caregiver, CNA, Home Health Aide, LPN, RN) *

Days Available *

Hours Available *

AM

PM

Graveyard

For specific Day/Hour availability, please enter information below.

Please select what cities you prefer to work in *

Oakland County

Macomb County

Monroe County

Washtewnaw County

Livingston County

Livingston County: All of Livingston County

Oakland County: All of Oakland County

Macomb County: All of Macomb County

Monroe County: All of Monroe County

Washtenaw County: All of Washtenaw County

What date are you available to start work? *

MM / DD / YYYY

EDUCATION:

Name and Address Of School - Degree/Diploma - Graduation Date *

Skills and Qualifications: Licenses, Skills, Training, Awards *

CPR Card Expire Date

MM / DD / YYYY

First Aide Expire Date

MM / DD / YYYY

Date of your last TB Test

MM / DD / YYYY

Please check which of the following skills you can perform: *

EMPLOYMENT HISTORY:

Present Or Last Position:

Employer: *

Address: *

Supervisor: *

Phone Number *

### - ### - ####

Email

Position Title: *

Start Date *

MM / DD / YYYY

End Date *

MM / DD / YYYY

Responsibilities: *

Salary *

Input hourly wage, if not salaried.

Reason for Leaving: *

Previous Position

Employer: *

Address: *

Supervisor: *

Phone Number *

### - ### - ####

Email

Position Title: *

Start Date *

MM / DD / YYYY

End Date *

MM / DD / YYYY

Responsibilities: *

Salary *

Input hourly wage, if not salaried.

Reason for Leaving: *

May We Contact Your Present Employer? *

Yes

No

References:
Name/Title Address Phone *

Don't have a scanner? You can download this free app named "Scan to PDF Free". You will be able to take a picture of your document and save it as a PDF file for upload to the application web site.

Resume Upload

Document Upload

Date *

MM / DD / YYYY

Authorization

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 grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of Loving Care Home Care of Canton, LLC has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized Loving Care Home Care of Canton, LLC representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

Loving Care Home Care of Canton, LLC is an Equal Employment Opportunity (EEO) employer and does not discriminate on the basis of race, color, national origin, religion, gender, age, veteran status, political affiliation, sexual orientation, marital status or disability (in compliance with the Americans with Disabilities Act) with respect to employment opportunities.

Employee Signature *

Clear

Please sign your legal first and last name above. This can be completed with your finger when using a android based smart phone, iPhone, Tablet, iPad, or when using your computer with your mouse.

Where did you find our Employment Ad? *

Craigslist Ad

Indeed Ad

Other