Circle of Care - Application

PERSONAL
Last Name:	*
First Name:	*
Middle Initial:
Home Telephone:	*
Cell Phone:
Address:	*
City:	*
State:	*
ZIP:	*
Email:
Position Applied For:
Referred By:
Salary Desired (per hr):		USD
Available for Live-in Position:		Check if you are available for a live-in position
Schedule Restrictions for Live-in:
Available to work nights:		Check if you are available to work nights
Schedule Restrictions for nights:
Available to work weekends:		Check if you can work weekends
Schedule restrictions for weekends:
Are you at least 18 years old:	*
Valid Maryland CNA or GNA or other license:		Check if you have a valid MD State professional license
EDUCATION
Highest H.S. Grade Completed:	*
High School address:
High School Major Studies:
High School Degree / Diploma / License / Cert:
College / Business / Trade School:
College / University address:
College / University Major:
College / University Degree or License:
Other School (Trade / Business) Address:
Other School Major Studies:
Other School Degree / Certification / License:
List Professional Designations (CNA / GNA / RN):
Other Special Knowledge / Skills / Qualifications:
EMPLOYMENT
Employer Name:	*
Employer Address:	*
Employer Start Date:	*	Calendar
Employer End Date:	*	Calendar
Supervisor:	*
Supervisor Phone:
Job Title:	*
Starting Salary:	*
Ending Salary:	*
Reason for leaving:
Duties & Reponsibilities:
ADDITIONAL EMPLOYMENT
Employer 2 Name:
Employer 2 Address:
Employer 2 Start Date:		Calendar
Employer 2 End Date:		Calendar
Employer 2 Supervisor:
Employer 2 Supervisor Phone:
Employer 2 Job Title:
Employer 2 Starting Salary:
Employer 2 Ending Salary:
Employer 2 Reason for Leaving:
Employer 2 Duties & Reponsibilities:
GENERAL
May we contact your employer for references:
Will you need special accommodations:		Yes, I will need special accommodations to perform the essential job duties for the position
Have you ever been convicted of a crime:		Any crime, excluding traffic offenses which did not result in loss of points, which has not been annulled, expunged, or sealed by a court? (Does not automatically disqualify you)
CERTIFICATION & AUTHORIZATION
I agree with the Certification and Authorization:	*	(see link at the top of this form)
Security Code:		Enter the code shown above in the box below

* required