Application

Name *

First

Last

Email *

Address *

Address

Address 2

City, State *

Zip Code *

Cell Phone *

Home Phone

Have Worked For This Company Before? *

If yes, please give the date, position, and reason for leaving.

Please Type Your Response Above

Work Authorization/Are you Authorized to Work In This Country? *

How did you hear about this opportunity? *

Were you referred by a current employee? Please give the name.

Criminal Record: Due to the nature of SeniorCare Xpress, it is necessary to ask about an applicant's conviction record, since this would have a direct effect on the ability to meet program objectives and requirements. Have you ever been convicted of any crime excluding minor traffic offense? *

If Yes, please explain in FULL detail:

Please Type Your Response Above

Specifically, our licensing standards require documentation regarding any applicant having been either convicted of, or leaving previous employment due to any of the following: (1) Any sex offense, (2) Endangering children, (3) Corrupting another with drugs, (4) Trafficking in drugs, (5) Any crime of violence, (6) Child abuse or neglect. Have you been convicted of or left previous employment due to any of the above reasons? If Yes, Please Explain: *

Please Type Your Response Above. Answer Yes or No

Please provide the following requested information regarding your employment history: Include military service assignments and volunteer activities. You may exclude organization names that include race, color, religion, gender, national origin, ancestry, age, disability or other protected status. Current or Most Recent Employer. Are you currently employed? *

Company Name 1

Address 1

City, State, Zip 1

Company Phone1

May We Contact? 1

From Date 1

To Date 1

Responsibilities and Duties 1

Please Type Your Response Above

Reason for Leaving 1

Please Type Your Response Above

Company Name 2

Address 2

City, State, Zip 2

May We Contact? 2

From Date 2

To Date 2

Responsibilities and Duties 2

Please Type Your Response Above

Reason for Leaving 2

Please Type Your Response Above

Company Name 3

Address 3

City, State, Zip 3

Company Phone 3

May We Contact? 3

From Date 3

To Date 3

Responsibilities and Duties 3

Please Type Your Response Above

Reason for Leaving 3

Please Type Your Response Above

Have you ever been discharged or asked to resign by an employer? *

If yes, please explain:

Please Type Your Response Above

Education/Training: What is your highest level of education completed? *

Name of institution(s) *

Please Type Your Response Above

Did you Graduate? *

Degree(s) or Certification(s)

Please Type Your Response Above

List any professional licenses...

Please Type Your Response Above

Licensure Name and Number

Please Type Your Response Above

Reference 1 *

First

Last

Company 1 *

Relationship 1 *

Reference Phone 1 *

Email 1 *

Years Known 1 *

Reference 2 *

First

Last

Company 2 *

Relationship 2 *

Reference Phone 2 *

Email 2 *

Years Known 2 *

Reference 3 *

First

Last

Company 3 *

Relationship 3 *

Reference Phone 3 *

Email 3 *

Years Known 3 *

Applicant's Statement All of the information I have supplied on this Application is true and complete to the best of my knowledge and I have not knowingly withheld any information that, if known to SeniorCare Xpress, would affect my Application unfavorably. In the event, I enter into an employment agreement with SeniorCare Xpress, and if SeniorCare Xpress discovers at any time during the employment that any of the statements or answers on this Application are false, misleading or incomplete, I understand that I may be terminated immediately from my job. I give SeniorCare Xpress my permission to conduct an investigation regarding the information contained in my Application that SeniorCare Xpress thinks is necessary to determine my qualifications for employment with SeniorCare Xpress. I give SeniorCare Xpress my permission to contact any former employer, school, college or university, utility company, credit or finance bureau or office, any personal or professional reference or any other appropriate source or individual for the purpose of gathering any information, personal or otherwise, that said sources may have about my character, general reputation, credit, education or employment record, and I give my consent to any such source to release to SeniorCare Xpress, whatever information they have about me. I also unconditionally release SeniorCare Xpress, its Board, administration and staff and all named and unnamed sources from any and all liability which might result in furnishing any information about me. If I am extended an offer of employment, I agree to submit a medical examination that may include testing for drugs or alcohol prior to beginning employment and I understand that any employment offer is conditioned upon passing such medical examination and/or testing. I agree to release to SeniorCare Xpress or its designated agents, all medical information, including but not limited to, files, reports, x-rays, evaluations and opinions held by medical personnel, to the extent such information is job-related and consistent with SeniorCare Xpress business needs, and agree to execute the necessary HIPAA - compliant release. I acknowledge that this is a general release and that if contracted by SeniorCare Xpress, it remains in effect for the duration of my employment relationship. I understand and agree that this Application, by itself or together with other SeniorCare Xpress policies and documents, does not create a contract of employment between SeniorCare Xpress and me. I also understand that, if I am hired, my employment can be terminated, either by SeniorCare Xpress or me at any time with or without cause, and with or without notice. In exchange for SeniorCare Xpress considering my application, I agree that any claim or lawsuit I have now or in the future against SeniorCare Xpress, its subsidiaries, successors, assigns, managers, employees and/or agents, must be filed by me within one (1) year from the date of the act or omission that is the subject of my claim or lawsuit, or within the applicable statute of limitations, whichever time period is shorter. Thus, I expressly waive any statute of limitations for any such claim or lawsuit longer than one (1) year, regardless of the nature of the claim or action. As further consideration for these promises by me, SeniorCare Xpress agrees to waive any statute of limitations longer than one (1) year from the date of the act or omission that is the subject of any claim or lawsuit they might file against me. I also understand that, if I am hired, my employment would be at-will, and subject to termination either by me, or by SeniorCare Xpress for any lawful reason, at any time, with or without cause, and with or without notice.

I have read and agree to this disclaimer. *

Sign Below *

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Application

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