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What days and times, including weekends, are you available to work?
What days and times are you not available to work?
Can you be called at the last minute for emergency assignments:
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Employment Eligibility
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Are you at least 18 years of age?
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Have you ever been convicted of a criminal offense?
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If yes, please state the nature of the crime (s), when and where you were convicted, and the disposition of the case:
*Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
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If no, describe the functions that cannot be performed:
Work Experience: (start with most recent job)
1. Company or Employer:
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Discuss any training or related experience working with the elderly that you have had:
Profesional References
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First
Relationship
Known for how many years:
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First
Relationship
Known for how many years:
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Name
First
Relationship
Known for how many years:
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**CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
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