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CAPRI PERSONAL CARE HOMES, CO. INC.PHONE: 281-931-3061 / FAX: 281-448-7397
APPLICATION FOR EMPLOYMENT
Applicant’s Name: / Social Security Number:
Current Home Street Address: / Apt: / City / State / Zip Code
18 or older? If yes list date of birth. / Are you 25 or older? / Are you a U.S. citizen? Or an alien authorized to work in the U.S.A?
Ever worked or attended school under any other name? / List Home Phone, Cell, and/or Fax #’s
Ever been convicted of a crime? If yes, give dates & details in space provided below:
A yes, answer will automatically disqualify you from this job. We consider the nature & date of the offense, & the job you are applying for, job related purposes only, & only to the extent permitted by applicable law.
POSITION DESIRED
Title of Position you are applying / Date you can start work / Daily/ Hourly rate desired?
Full Time/ Part Time / If P/Time- How many hours? / Days of week available? / Hours available?
Available to work weekends? / Holidays? / Nights? / Overtime?
Are you related to a current or former employee of Capri Homes or another HCS Provider? If yes, please provide employee name.
Have you ever worked for Capri Homes or another HCS Provider? If so, state when/where:
EDUCATION
High School: / Graduated? Yes/No / Course of Study?
Technical School: / Graduated? Yes/No / Course of Study?
College/ University: / Graduated? Yes/No / Course of Study?
Other education or training:
Other special skills:
OVER FOR ADDITIONAL INFORMATION & WORK HISTORY
CAPRI PERSONAL CARE HOMES, CO. INC.
PHONE: 281-931-3061 / FAX: 281-448-7397
WORK EXPERIENCE
PLEASE LIST ALL PREVIOUS EMPLOYMENT, BEGINNING WITH THE MOST RECENT. IF YOU NEED ADDITIONAL ROOM – YOU MAY ATTACH ANOTHER SHEET OF PAPER. (IN OFFICE ONLY)
Current or most recent employer: / Company address:
Phone and or fax: / Supervisor Name: / Okay to contact: Yes/No? / Reason for Leaving
Position Held / From / To / Beginning Pay Rate / Ending Pay Rate
Describe you duties:
Previous Employer: / Company address:
Phone and or fax: / Supervisor Name: / Okay to contact: Yes/No? / Reason for Leaving
Position Held / From / To / Beginning pay rate / Ending Rate
Describe your duties:
Previous Employer: / Company address:
Phone and or fax: / Supervisor Name: / Okay to contact: Yes/No? / Reason for Leaving
Position Held / From / To / Beginning pay rate / Ending Rate
Describe your duties:
Previous Employer: / Company address:
Phone and or fax: / Supervisor Name: / Okay to contact: Yes/No? / Reason for Leaving
Position Held / From / To / Beginning pay rate / Ending Rate
Describe your duties:
Previous Employer: / Company address:
Phone and or fax: / Supervisor Name: / Okay to contact: Yes/No? / Reason for Leaving
Position Held / From / To / Beginning pay rate / Ending Rate
Describe your duties:
AUTHORIZATION & ACKNOWLEDGMENTS
I hereby authorize any investigator or duly accredited representative of Capri Personal Care Homes, Inc. bearing this release to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. I herby direct you to re-lease such information upon request of the bearer. I understand that the information is for the official use by Capri Personal Care Homes, Inc. and may be disclosed to such 3rd parties as necessary in the fulfillment of official responsibilities. I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.
Applicant Electronic Signature: / Date
(Above authorizes to begin review of employment history & criminal history checks)
CAPRI PERSONAL CARE HOMES, CO. INC.|Confidential Application /