CAREGIVER EMPLOYMENT OPPORTUNITIES

Time Availability:  (check all times you are available for work; times noted are approximate)

EDUCATION

High School

Did you graduate?

College

Did you graduate?

CURRENT AND PREVIOUS EMPLOYMENT

May we contact your previous supervisor for a reference?

May we contact your previous supervisor for a reference?

May we contact your previous supervisor for a reference?

PROFESSIONAL REFERENCES  ( Please list three professional references. )

Please comment regarding any other education, foreign languages, training or special skills you possess which you believe may be related to your ability to perform this position

Employment Application Disclosure and Authority to Release Information

PLEASE READ THIS STATEMENT CAREFULLY BEFORE SIGNING.

I understand that in processing my application with CritiCare Home Health and Nursing Services, an investigative background check will be conducted. Any such background check may contain information bearing on my character, general reputation, education, personal characteristics and mode of living. Information may include, but is not limited to: employment history, education, criminal records, national sex offender check, child abuse clearance, fraud, motor vehicle records, personal references and any data provided on this application or during the interview process.

If currently employed:  My current employer may be contacted

I authorize the appropriate individuals, companies, institutions or agencies to release information and I release them from any liability as a result of such inquiries or disclosures.  I further understand and waive my right in this investigation and release and hold harmless CritiCare Home Health and Nursing Services from any liability.

I have read, understand, and by my signature consent to these statements.  I hereby certify that all the statements and answers set forth on the application form, my resume and interview are true and complete to the best of my knowledge.  If this application leads to employment, I understand that if any statements and/or answers are found false or the information has been omitted, such false statements or omissions may be cause for rejection of my application or termination of my employment. 

Please list any additional addresses you have lived, worked and attended schools in during the past 5 years:

I authorize a photocopy of this release to be accepted with the same authority as the original and if employed by the above name company this release will remain in effect throughout such employment.