Job Applying for?
Companion
RN
Secretary
Assistant
Caregiver
Certified nursing assistant
Transporter
Name
*
First Name
Last Name
Date
MM
DD
YYYY
Are you seeking:
When could you start work?
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Social Security #
Email
*
Subject
*
Message
*
If hired, can you provide proof you are eligible to work in the U.S.?
Have you ever applied here before?
If yes, when?
If yes, when?
Were you ever employed here?
If yes, when?
Have you ever been convicted of any law violations? (including traffic violations)
If yes, give details:
(A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.)
Are you now or do you expect to be engaged in any other business or employment?
If yes, please explain:
For Drivers Only: Do you have a valid driver’s license?
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Driver’s License Number
*
State of License
*
Class of License
*
Have you had your driver’s license suspended or revoked in the last 5 years?
*
If yes, please describe:
*
List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal age, race, sex, color, religion, national origin, disability or other protected status.) You may also attach a copy of your achievements or awards for more credibility.
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LIST NAME AND ADDRESS OF SCHOOLS
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High School or GED Name Address # of Years Diploma/Certificate Subject Studied
College or University Name Address # of Years Diploma/Certificate Subject Studied
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Vocational or Technical Name Address # of Years Diploma/Certificate Subject Studied
What skills or additional training do you have that are related to the job for which you are applying?
What machines or equipment can you operate that are related to the job for which you are applying?
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Is there anything you would like to know about Compassionate Companions LLC?
List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR.
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NAME OF EMPLOYER CITY, STATE ZIP CODE SUPERVISOR PHONE
DATES OF EMPLOYMENT: FROM TO PAY: START $ FINAL $ REASON FOR LEAVING
NAME OF EMPLOYER CITY, STATE ZIP CODE SUPERVISOR PHONE
DATES OF EMPLOYMENT: FROM TO PAY: START $ FINAL $ REASON FOR LEAVING
NAME OF EMPLOYER CITY, STATE ZIP CODE SUPERVISOR PHONE
DATES OF EMPLOYMENT: FROM TO PAY: START $ FINAL $ REASON FOR LEAVING
NAME OF EMPLOYER CITY, STATE ZIP CODE SUPERVISOR PHONE
DATES OF EMPLOYMENT: FROM TO PAY: START $ FINAL $ REASON FOR LEAVING
NAME OF EMPLOYER CITY, STATE ZIP CODE SUPERVISOR PHONE
DATES OF EMPLOYMENT: FROM TO PAY: START $ FINAL $ REASON FOR LEAVING:
Have you worked or attended school under any other name?
Are you presently employed?
If yes, may we contact your present employer?
Have you ever been fired from a job or asked to resign?
*
If yes, please explain:
Give three references, not relatives or former employers.
*
Name Address Phone
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that the Compassionate Companions LLC may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation. I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organization from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/o r post-employment drug screen as a condition of employment, if required. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF COMPASSIONATE COMPANIONS LLC AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read, understand, and by my signature consent to these statements.
Signature Date
Name
First Name
Last Name
If yes, please list here:
Do you have any allergies that would specialize your employment with Compassionate Companions LLC?
Do you have a problem working with a client who smokes?
How many hours are you willing to work per week?
Is there anything that may intervene with you taking on a case such as another job, school, or having to take care of a family member etc?
If yes, please explain:
Do you have any medical concerns that may cause you not to be able to take on a potential case?
If yes, please explain
Are you able to work split shifts?
Are you able to take on more than one case at a time?
Would you be available to be on call to fill in for a last minute case?
Locations that you are willing to work:
Please select all those that apply, and/or write in requested additional locations
Please list all time and days of the week you are available
Company Name
Manager's Name
Company Address
Phone
(###)
###
####
Reason for leaving this company:
I authorize Compassionate Companions LLC and/or the staff member listed above to release information about me to Compassionate Companions LLC or authorized staff
Do you have any additional notes about professional reference?
Company Name
Manager's Name
Company Name
Phone
(###)
###
####
Reason for leaving this company:
I authorize Compassionate Companions LLC and/or the staff member listed above to release information about me to Compassionate Companions LLC or authorized staff
Do you have any additional notes about this professional reference?
Background Check Authorization
Complete the following information as accurately as possible
First Name
Last Name
SSN:
D.L. #
Birth date:
Phone
(###)
###
####
Addresses: List past seven years beginning with your current address. Include street, city, state, zip code, county and dates of residence.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is there anything you would like Compassionate Companions LLC to know in regard to your past history?
BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM In the interest of maintaining the safety and security of our customers, employees and property, Compassionate Companions LLC will order a “consumer report” (a background report) or “investigative consumer report" on you in connection with your employment application, and if you are hired, or if you already work for Compassionate Companions LLC, you may order additional background reports for employment purposes. The background check will be conducted by the FBI. The Fingerprinting will be completed at the North Hills Post office. The address is 4971 McKnight Road Pittsburgh, PA 15237. You will register through the FBI website first and then through the post office website. There will be an attached sheet with the websites for both parties and instructions on how to submit your information. The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; drug testing results; and, if applicable, worker’s compensation injuries. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local laws and only after a conditional job offer is made. Credit history will only be requested when permitted by law and where such information is substantially related to the duties and responsibilities of the position for which you are applying. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An “investigative consumer report” is a background report that includes information from such personal interviews, except in California where that term means any background report that is not a credit report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by the Background Check Company or another outside organization. You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You will find these rights summarized on A Summary of Your Rights Under the Fair Credit Reporting Act and A Summary of Your Rights Under the Provisions of California Civil Code Section 1786.22 for California residents. I understand that my date of birth is used solely as an identifier to avoid possible misidentification while completing the background check process. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as the original.
Printed Name
