Platinum Eldercare - Job Application Form - Caregiver/Personal Attendant

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Platinum Eldercare

In-Home Care Provider

Employment Application

Employment Desired

Position applying for: Caregiver / Personal Attendant

Employment History

List below all present and the last 5 years past employment starting with the most recent employer. Account for all periods of unemployment. You must complete this section even if you also submit a resume.
Employer Name: Telephone:
Type of Business: Supervisors Name:
Address: City: State: Zip:
Date of Employment: from to Weekly Pay: starting ending
Your Position & Duties:
Reason for Leaving:
May we contact this employer for a reference? Yes No
Employer Name: Telephone:
Type of Business: Supervisors Name:
Address: City: State: Zip:
Date of Employment: from to Weekly Pay: starting ending
Your Position & Duties:
Reason for Leaving:
May we contact this employer for a reference? Yes No
Employer Name: Telephone:
Type of Business: Supervisors Name:
Address: City: State: Zip:
Date of Employment: from to Weekly Pay: starting ending
Your Position & Duties:
Reason for Leaving:
May we contact this employer for a reference? Yes No
Employer Name: Telephone:
Type of Business: Supervisors Name:
Address: City: State: Zip:
Date of Employment: from to Weekly Pay: starting ending
Your Position & Duties:
Reason for Leaving:
May we contact this employer for a reference? Yes No
Employer Name: Telephone:
Type of Business: Supervisors Name:
Address: City: State: Zip:
Date of Employment: from to Weekly Pay: starting ending
Your Position & Duties:
Reason for Leaving:
May we contact this employer for a reference? Yes No

References

List below three persons not related to you who have knowledge of your work performance within the last three years.
First Name: Last Name: Phone:
Address: City: State: Zip:
Occupation: Years Acquainted:
First Name: Last Name: Phone:
Address: City: State: Zip:
Occupation: Years Acquainted:
First Name: Last Name: Phone:
Address: City: State: Zip:
Occupation: Years Acquainted:

Please Read Carefully and Check Off each Paragraph Below

Please make a selection. I hereby certify that I have not knowingly withheld any information that might adversely affect chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Please make a selection. I hereby authorize Platinum Eldercare to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
Please make a selection. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.
Please make a selection. Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
Please make a selection. I waive receipt of a copy of any public record described in the paragraph above.

Please fax any additional information to:
(858) 792-2899
Please include your Name and Phone number on the top of each page.