Employment Application Please answer all questions. Prospective applicants will receive consideration without discrimination due to race, creed, color, sex, age, national origin, handicap or veteran status. Name: Address: Apt. #: City: State: Zip: Phone: Cell: Pager: Passport: Other: DOB: Auto Insurance Company: Education: High School: College: Other: Special Skills: Are you a: RN: LPN: CNA: HHA: Hm/Cmp: License Number: Current: Yes No Exp. Date: Have you ever been convicted of a felony?: Yes No If yes, please explain: Do you drive: Yes No Do you have dependable transportation: Yes No If no, how will you get to the job: What hours are you available to work? Days? Available in an emergency? Yes No Live-In? Yes No Have you worked with seniors in their home previously? Yes No Do you have any health or physical limitations? Yes No Please go back 5 years and tell us about your work history: Emergency Contact: Name: Relationship: Phone: Business References: Name: Phone: Name: Phone: Personal References: Name: Phone:

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