Contact Us

Application for Employment


Personal Information

First Name

Last Name

Social Security Number


Present Address

City

State

Zip Code


Mailing Address, if different

City

State

Zip Code


Phone Number


Have you ever been convicted of a felony?

If so, please explain

Do you have a current Driver's license?

License #

State


Employment Desired

Position

Date Available to Start

Salary Desired

Are you currently employed?

If so, may we contact your current employer?

Have you applied with us before?

If so, when?


Availability

Are you willing to work 24-hour live-ins?

How many hours per week do you want to work?

How far are you willing to drive?

What days and hours are you willing to work?


Education History

High School

Years Attended

Did you graduate?

Subjects Studied




College

Years Attended

Did you graduate?

Subjects Studied


Employment History

Company Name

Dates Employed

Address and Phone

Salary

Position


Company Name

Dates Employed

Address and Phone

Salary

Position


Company Name

Dates Employed

Address and Phone

Salary

Position


Company Name

Dates Employed

Address and Phone

Salary

Position


Special Skills and Licenses

Do you have a current Oregon CNA license?

If so, when does it expire?

What is the license number?

Any other skills or licenses?


Personal References

Name

Phone

Relationship

Years Known


Name

Phone

Relationship

Years Known


Name

Phone

Relationship

Years Known



"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 grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give 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 also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

By clicking to the "I AGREE" button below you are in effect signing this document and agreeing to the above Authorization

Date