Care Connection Inc. | Wantagh NY | Care for Seniors | Disabled | Home | Hospital | Assisted Living | Staff | Bonded | Insured | Long Island

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Online Employment Application

General Information
Position Desired*		Date Available (mm/dd/yy)*
First Name*		Middle
Last Name*		Address*
ZIP Code*		State*
Home Telephone		Email*
Cell Phone		Are you at least 18 years old?	Yes No
Have you been convicted* of a felony within the last 7 years?*			Yes No
Please explain. A conviction will not necessarily disqualify an applicant from employment.
Certification Certificate
Type HHA PCA CNA LPN		Certificate/License #
Date issued		Issued By
Expiration Date
Education and Training
High School
School Name		City, State
Graduated?	Yes
College
College Name		City, State
Degree/Major		Graduated?	Yes
Vocational Training
School Name		City, State
Degree/Major		Graduated?	Yes
Other
School Name		City, State
Training Received		Graduated?	Yes
Employment History
Please list most recent employer first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here.
Employer		Company Name
Company Address		Company Phone
From (Month/Year)		To (Month/Year)
Your Position		Supervisor's Name
Supervisor's Position		Starting Salary
Ending Salary		Responsibilities
Reason for Leaving		May we contact your previous supervisor for a reference? *	Yes No
Knowledge, Skills, and Abilities
List skills you possess and believe are pertinent to the position you seek, such as computer skills, fluency in language, supervisory skills.

References
List persons who know your work professionally, excluding supervisors
Reference Name		Organization/Position *
Telephone		Email
Relationship * No family, please.		Years Known * (Rounded to the nearest year)
What days do you prefer to work?		What hours do you prefer to work?
What days are you not available?		Will you be able to work weekends?	Yes No
Will you be able to work holidays?		Yes No
Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied?			Yes No
Desired employment type *	Full-time	Part-Time	Temporary
Salary Requirement $		per Year
Were you employed previously by us?	Yes No	When?
Do you have any relatives that work for us?	Yes No	Please be specific.
How were you referred to us?		Are you first aid certified?	Yes No

I certify that answers given herein are true and complete to the best of my knowledge.

I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.

I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision.

I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon satisfactory outcome of a medical examination and criminal background check.

I understand that my employment may be terminated at any time, without liability to me for wages and salary except as have been by me at the date of such termination.

Yes

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