* = Required Information
Personal Information
Name * Last Name * First
* Address
* City:
* State:	TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
* Zip:
*Phone:
* Email:
* Emergency Contact Name
* Emergency Phone Number
* Date of Birth
* Social Security No.
* Driver's License / ID
Desired Employment
* Position Applied for
* Date you can start:
* Rates Desired:
* Are you employed now?	Yes No
If so, may we make an inquiry of your present employer?	Yes No
* Who referred you to this company?
* Are you applying for:	Full Time Part Time PRN
Licensure/Certification
* License Type	CNAMALPNRNNone
License/Certification No.
State	TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Education
School Level School / Location Years Attended Graduated? Subjects Studied * CNA / MA / Both Please selectCNAMABoth Yes No College Yes No Trade, Business or Correspondence School Yes No Highschool Yes No
Employment History
List your last two employers, starting with the most recent one first
* Name of present or last employer:
* Address
* City
* State	TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
* Zip
* Start Date
* End Date
* Job title
* Hourly Starting Rate
* Hourly Ending Rate
May we contact your supervisor?
*Name of supervisor
*Phone
* Description of work
* Reason for leaving:
* Name of Employer:
* Address
* City
* State	TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
*Zip
* Start Date
* End Date
* Job title
*Hourly Starting Rate
* Hourly Ending Rate
* May we contact your supervisor?
* Name of supervisor
* Phone
* Description of work
* Reason for leaving:
Personal References
Below, give the names of three persons you are not related to whom you have known for at least one year.
Name Address Relationship Phone Number Years known 1. * * * * * 2. * * * * * 3. * * * * *
Are you legally authorized to work in the USA? *	Yes No
(Should you become employed by Courtesy Care, Inc., you will be required to provide documentation proving your eligibility to work in the USA).
* Have you ever been convicted of any violations of law (felony or misdemeanor crime), including traffic violations?	Yes No
What crime and dates of conviction or charge?
* Are you over 18 years of age and own a car ?	Yes No
* Do you carry a liability car insurance coverage?	Yes No
* Do you have any physical problems that may limit your ability to perform this job?	Yes No
Please explain
Authorization
I authorize Courtesy Care, Inc. to obtain any relevant information (including extensive local and national criminal background checks, social security verification, credit history, and motor vehicle investigations) needed to make an employment decision. I authorize Courtesy Care, Inc. to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal contractual, or accreditation audits purposes which is valid for 180 days from date of signature of this application.
I also authorize Courtesy Care, Inc. to disclose any of my performance appraisals, disciplinary records, or skills tests for the same purposes as above. I release Courtesy Care, Inc. from any individual or entity providing information to Courtesy Care, Inc. from all liability for any damages from the disclosure of the information.
I understand and agree that nothing contained in this employment application or in granting an interview, creates an employment contract between Courtesy Care, Inc. and I for either employment or for the providing of any benefits. No promises regarding employment have been made to me. If I am offered employment, I understand it is conditional upon a clear criminal background check and that employment can be terminable at will, and I have a right to terminate my employment at any time and that Courtesy Care, Inc. also retains a similar right to terminate my employment at any time.
I understand that should I become employed by Courtesy Care, Inc., my work assignments, schedules, and work locations are subject to change according to the needs of the business and the clients of Courtesy Care, Inc.. I further authorize Courtesy Care, Inc. to perform periodic criminal history background checks and released/received any information and inquiries from federal, government, or state program for the duration of my employment with this company.
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 considered grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed to 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 hereby agree that I will NOT solicit direct employment from clients assigned to me by Courtesy Care, Inc. I understand that failure to comply with this agreement would result in a $3,000.00 employee-release fee to be paid by me to Courtesy Care, Inc.
* Signature
* Date
* Security Code