8191 Southpark Lane, Suite 206

Littleton, CO 80120

Phone: 303-791-3155, Fax: 303-683-4484

EMPLOYMENT APPLICATION

This agency is committed to the provision of equal employment opportunity. We prohibit unlawful discrimination against applicants or employees on the basis of age, race, pregnancy, sex, color, religion, national origin, disability, sexual orientation, gender, gender identity, religion,, marital or military service member status, citizenship status, or physical attributes or characteristics (“protected characteristic”), or any other applicable characteristic or status that may be protected by state or local law. This prohibition includes unlawful harassment based on any of these protected classes. Unlawful harassment includes verbal or physical conduct which has the purpose or effect of substantially interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment. This policy applies to all employees, including managers, supervisors, co-workers and non-employees such as customers, clients, vendors, consultants and so forth. This application is intended to allow you to provide our organization with information from which suitability for the position for which you are applying can be determined. We pride ourselves in providing excellent care to our clients. We are looking for people who want to contribute to that quality. We are interested in people who enjoy serving people. And we are interested in people who are not only willing, but anxious to work hard to achieve the highest standards of care.

(Please Print) Date of Application ______

Name ______

Last First Middle

Address ______

Street City State Zip Code

Social Security Number ______Telephone Number ______

E-mail Address; ______

Position Applied For ______

Are you 18 years of age or older? □ yes □ no

If under 18, can you, after employment, submit a work permit? □ yes □ no

How did you hear about us? □ Advertisement □ Employment Agency □ Friend/ Relative

□ Employee □ Other ______

For checking prior work/education records, list all the names you have been known by:

______

______

______

List friends and/ or relatives presently working at this facility: ______

Have you ever applied for this company before? □ yes □ no Date ______

Have you ever worked for this company? □ yes □ no Date ______

Are you legally qualified to work in the US? □ yes □ no

Are you able to pass a criminal background check? □ yes □ no

Are you able to pass a driving record check? □ yes □ no

Have you ever been convicted of a felony or a misdemeanor crime? □ yes □ no

Are available to work: □ Full Time □ Part Time □ Temporary □ On Call

□ Sun □ Mon □ Tue □ Wed □ Thur □ Fri □ Sat □ Sun □ Holidays

□ Mornings □ Afternoon □ Evenings □ Over nights

Date Available to start work: ______Minimum Salary desired: ______

Do you have any obligation which might affect your work schedule? ______

______

THIS IS A SEVEN DAY WEEK OPERATION, IN APPLYING FOR EMPLOYMENT, IT IS UNDERSTOOD ALL EMPLOYEES WILL WORK THEIR FAIR SHARE OF WEEKENDS AND HOLIDAYS WITHIN THEIR JOB CLASSIFICATION.

We run a 6 step background check on all eligible candidates. As part of this 6 step check you will be asked to provide information for the past ten years. This includes but is not limited to residential history, educational history, work history etc.

Are you able to perform the essential functions of the job for which you are applying? □ yes □ no

Are you able to stand for extended periods of time? □ yes □ no

Are you able to lift 80 lbs. or more? □ yes □ no

In Case of emergency, notify:

______

Name Relationship Phone Number

Please check the specialty areas that best match your experience/ education and interests

Homecare □ / C.N.A. □ / LPN □ / RN □ / SNF □
Hospital □ / Geriatric □ / Residential Care □ / Home Making □ / Group Home □
Dementia Care □ / Alzheimer’s Care □ / Assistive Devices □ / CPR Training □ / Other □

RESIDENTIAL HISTORY

St. Address / City / State / Zip Code / Dates of Residence

EDUCATION/SKILLS

School / Name of School
City/State / Years Completed / Course of Study / Did you Graduate? / Degree or Diploma
High
School / □ yes
□ no
College / □ yes
□ no
Trade School / □ yes
□ no
Other / □ yes
□ no

Special Courses (Military training, apprenticeship program, vocational training, any Continuing Education Courses/ Seminars taken in your professional field):

______

______

______

PROFESSIONAL LICENSES AND /OR CERTIFICATES

TYPE / ACTIVE/INACTIVE / STATE ISSUED / DATE OF EXPIRATION / NUMBER / VERIFIED
(office use only)

EMPLOYMENT EXPERIENCE-

List both part-time and full-time jobs Start with present or last job.

Company Name / Telephone
Address / Employed (state month and year)
From To
Name of Supervisor / Salary
Start Present (or ending)
Job title and job duties / □ Full Time
□ Part time Hour per week
May we contact this employer?
□ yes □ no why not? / Reason for Leaving
Company Name / Telephone
Address / Employed (state month and year)
From To
Name of Supervisor / Salary
Start Present (or ending)
Job title and job duties / □ Full Time
□ Part time Hour per week
May we contact this employer?
□ yes □ no why not? / Reason for Leaving
Company Name / Telephone
Address / Employed (state month and year)
From To
Name of Supervisor / Salary
Start Present (or ending)
Job title and job duties / □ Full Time
□ Part time Hour per week
May we contact this employer?
□ yes □ no why not? / Reason for Leaving
Company Name / Telephone
Address / Employed (state month and year)
From To
Name of Supervisor / Salary
Start Present (or ending)
Job title and job duties / □ Full Time
□ Part time Hour per week
May we contact this employer?
□ yes □ no why not? / Reason for Leaving

REFERENCES

Give below the names of three persons not related to you, whom you have known at least one year.

Name / Phone Number / Business / Years known

AUTHORIZATION

“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 also authorize investigation of all statements contained in this application for employment 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 damages that may result from utilization of such information as may be necessary in arriving at an employment decision.

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 and authorized company representative.

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

"I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written documentation or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization."

DATE: ______SIGNATURE: ______

X:\HR/CAN & PCW/ Staff Development/ Employment Application