Apply Contact InformationCover LetterIf Desired Drop files here or Select files Accepted file types: pdf, doc, docx, txt, Max. file size: 100 MB. ResumeIf Available Drop files here or Select files Accepted file types: pdf, doc, docx, txt, Max. file size: 100 MB. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Birthday* Month Day Year Primary Phone*Secondary PhoneCan We phone you at work?* Yes No EducationWhat was the highest grade completed?* 12 11 10 9 8 7 6 5 4 3 2 1 How many years of post high school education have you completed?* 7 6 5 4 3 2 1 0 What schools did you attend?*Name of SchoolDegreeMajorMinorDates Attended Add Remove*** If you expect to complete an education program in the near future, please indicate what type of degree or program and expected completion date.Position you're applying for* Work ExperienceWork Experience (Add as many as necessary)*EmployerTitleAddressPhoneType of BusinessSupervisorStart DateEnd DateHour/WeekStarting SalaryEnding salaryNumber of Employees You SupervisedIf your name was different, what was it?Reason for Leaving (if currently employed, may we contact them?)Duties Add RemoveAdditional Information*Use this space for any additional information you think would help us evaluate your employment application, including training, seminars, workshops, special achievements, or specialized skillsList office equipment with which you are familiar:List medical equipment with which you are familiar:List any Licenses/certificates that you hold which are required for the position:ReferencesRefences*NameAddressPhoneRelationship Add RemoveList 3 or more referencesMiscellaneousWhat shift(s) are you willing to work?* Day Evening Night What status are you looking for?* Full-Time Part-Time On-Call Are you legally eligible to work in the US?* Yes No When are you able to start work* Month Day Year What is your desired hourly rate of pay?* How did you hear about this opportunity?* Drivers License InformationState*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificState License Number* Type Expiration Date* Month Day Year Accident Record For Past 3 Years or MoreDatesNature of Accident (Head-On, Rear End, Upset, etc.)Number of FatalitiesNumber of Injuries Add RemoveTraffic Convictions and Forfeitures for the Past 3 YearsDate ConvictedViolationLocation of ViolationPenalty Add RemoveHave you ever been denied a license, permit or privilege to operate a motor vehicle?*YesNoPlease Explain*Has any license, permit or privilege ever been suspended or revoked?*YesNoPlease Explain*Has any relative or significant other ever interview or work for Total Care Group?*YesNoWho and what's their relation?*TO BE READ AND SIGNED BY APPLICANT I authorize you to make investigations and inquiries to my personal and driver record and other related matters as may be necessary in arriving at an employment decision. I hereby release the Department of Motor Vehicles and other persons from all liability in responding to inquiries and releasing information in connection with my application. CERTIFICATION - I hereby certify that all of the information I have provided is true and complete. I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment with the company. I understand that employment is for no definite period and maybe terminated at anytime by the employer. I understand that all information on this employment application is subject to verification. I consent to references of former employers and educational instructors listed being contacted regarding this employment application.Digital Signature:* Date* Month Day Year
