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We are hiring!

Please fill out the application below.

Where did you receive your PCA? :
If you are a CNA is your license active? :  Yes No
Position desired: Referred by:
Date of Birth:
*Last Name: *First Name: *Middle Name:
*Street:
*City: *State: *ZIP Code:
Telephone: Cell: E-mail:
Type of employment desired:  Full Time Part Time PRN
Date available for work:
Have you ever been employed by HCC Personal Care, Inc. before? :  Yes No
Are you legally eligible for employment in this country?  Yes No
Have you ever been excluded from participation in any federal health care program?  Yes No
If yes, have you been reinstated? Date:
Have you ever been known by any other name?  Yes No
Please list name(s) :
Have you been convicted of a crime in the last five (5) years?  Yes No
If yes, please explain:

CONVICTION WILL NOT NECESSARILY MEAN YOU WILL NOT BE EMPLOYED. EACH CONVICTION WILL BE CONSIDERED RELATED TO THE POSITION YOU ARE APPLYING FOR.

Employment History

(Please begin with most recent employment)

From:
To:
Employer:
Phone #:
Job Title:
Address:
Fax #:
Immediate Supervisor and Title:
Hourly Rate/Salary:
Start $ per
Final$ per
From:
To:
Employer:
Phone #:
Job Title:
Address:
Fax #:
Immediate Supervisor and Title:
Hourly Rate/Salary:
Start $ per
Final$ per
From:
To:
Employer:
Phone #:
Job Title:
Address:
Fax #:
Immediate Supervisor and Title:
Hourly Rate/Salary:
Start $ per
Final$ per
From:
To:
Employer:
Phone #:
Job Title:
Address:
Fax #:
Immediate Supervisor and Title:
Hourly Rate/Salary:
Start $ per
Final$ per

Qualifications & Skills

(Please list below any additional job-related qualifications or skills.)

Educational Background

Name and Location Years Completed Year Graduated Course of Study
High School
College
Other

Additional Employment References

(Optional)

Name Company/Relationship Phone # Years Known

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, and educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration.

I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I certify that I have read and understand this form and seek employment under these conditions.

Signature of Applicant: Date:
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