Apply - Total Care Group

Contact Information

Cover Letter

If Desired

Drop files here or

Resume

If Available

Drop files here or

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Birthday*

MM

DD

YYYY

Primary Phone*

Secondary Phone

Can We phone you at work?*

Yes
No

Education

What was the highest grade completed?*

How many years of post high school education have you completed?*

What schools did you attend?*

Name of School	Degree	Major	Minor	Dates Attended

*** 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 Experience

Work Experience (Add as many as necessary)*

Employer	Title	Address	Phone	Type of Business	Supervisor	Start Date	End Date	Hour/Week	Starting Salary	Ending salary	Number of Employees You Supervised	If your name was different, what was it?	Reason for Leaving (if currently employed, may we contact them?)	Duties

Additional 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 skills

List 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:

References

Refences*

Name	Address	Phone	Relationship

List 3 or more references

Miscellaneous

What 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*

MM

DD

YYYY

What is your desired hourly rate of pay?*

How did you hear about this opportunity?*

Drivers License Information

State*

State License Number*

Type

Expiration Date*

MM

DD

YYYY

Accident Record For Past 3 Years or More

Dates	Nature of Accident (Head-On, Rear End, Upset, etc.)	Number of Fatalities	Number of Injuries

Traffic Convictions and Forfeitures for the Past 3 Years

Date Convicted	Violation	Location of Violation	Penalty

Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

Please Explain*

Has any license, permit or privilege ever been suspended or revoked?*

Please Explain*

Has any relative or significant other ever interview or work for Total Care Group?*

Who 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*

MM

DD

YYYY