Online Employment Application

Please answer all questions. Resumes are not a substitute for a completed application. CareScape is an equal opportunity employer. Applicants are considered for positions without regard to race, age, disability, or any other consideration made unlawful by applicable federal, state, or local laws.

"*" indicates required fields

Position Applied For*

Desired Wage*

Name*

Present Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

If you are under 18 and it is required, can you provide a work permit?*

Yes

Type of employment desired?*

Full-time

Part-time

Please specify hours*

Are you willing to work overtime?*

Yes

Date on which you can start*

Previous CareScape Employment

Have you ever applied to CareScape before?*

Yes

Have you ever worked for CareScape before?*

Yes

Date of Previous Employment

Previous Employment Position

Reason for leaving?

Driver’s license number if driving is a job function

Legal Record

Within the past ten (10) years, have you been convicted of, or pled no contest to, a felony or DUI?*

(Do not include convictions that were sealed, eradicated, erased, or expunged; or convictions that resulted in referral to a diversion program.)

Yes

If Yes, please explain the date of conviction and a description of charges so that individual circumstances can be considered. (Conviction will not necessarily be a bar to employment. Each instance will be considered in relation to the position for which you are applying.)

Past Convictions - Explanation

Have you ever initiated an act of violence in the workplace?*

Yes

If Yes, please explain so that individual circumstances can be considered. (A Yes answer will not necessarily disqualify you from employment.)

Workplace Violence - Explanation

Education

Technical Skills

High School

Course of Study

Years Completed

Degree/Major

Did you graduate from high school?

Yes

College

Course of Study

Years Completed

Degree/Major

Did you graduate from college?

Yes

Trade School

Course of Study

Years Completed

Degree/Major

Did you graduate from trade school?

Yes

Work Experience

Start with your present or last place of employment. You may include any verifiable work performed on a volunteer basis, internships, or military service.

Employer #1

1. Employer Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Business

Employment Start Date

Employment End Date

Job Title

Duties

Supervisor's Name

Phone

May we contact?

Yes

Wages Start

Final Wages

Reason for Leaving

Employer #2

2. Employer Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Business

Employment Start Date

Employment End Date

Job Title

Duties

Supervisor's Name

Phone

May we contact?

Yes

Wages Start

Final Wages

Reason for Leaving

Employer #3

3. Employer Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Business

Employment Start Date

Employment End Date

Job Title

Duties

Supervisor's Name

Phone

May we contact?

Yes

Wages Start

Final Wages

Reason for Leaving

References

Please list the names of additional work-related references we may call. Individuals with no prior work experience may list school or volunteer related references.

Reference #1

Reference #1: First and Last Name

First and Last Name

Reference #1: Position

Position

Reference #1: Company

Company

Reference #1: Work Relationship

Work Relationship (i.e., supervisor, co-worker)

Reference #1: Phone

Phone

Reference #2

Reference #2: First and Last Name

First and Last Name

Reference #2: Position

Position

Reference #2: Company

Company

Reference #2: Work Relationship

Work Relationship (i.e., supervisor, co-worker)

Reference #2: Phone

Phone

Reference #3

Reference #3: First and Last Name

First and Last Name

Reference #3: Position

Position

Reference #3: Company

Company

Reference #3: Work Relationship

Work Relationship (i.e., supervisor, co-worker)

Reference #3: Phone

Phone

Consent

Consent*

By consenting, I confirm all the information provided is true and that I have read and agree to the "Notes and Terms" as outlined below.

I UNDERSTAND THAT NEITHER THIS APPLICATION NOR ANY COMMUNICATION BY A MANAGEMENT REPRESENTATIVE IS INTENDED TO CREATE OR DOES CREATE A CONTRACT OF EMPLOYMENT, OFFER, OR PROMISE OF EMPLOYMENT. I ACKNOWLEDGE THAT IF HIRED BY THE COMPANY, EMPLOYMENT IS ON AN AT-WILL BASIS. THIS MEANS THE COMPANY IS FREE TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE OR ADVANCE NOTICE, IN ACCORDANCE WITH STATE LAW, AND ACCEPTANCE OF EMPLOYMENT IS NOT A CONTRACT OF EMPLOYMENT FOR ANY SPECIFIED TIME. SIMILARLY, I AM FREE TO TERMINATE MY EMPLOYMENT WITH THE COMPANY AT ANY TIME FOR ANY REASON. THIS AT-WILL PROVISION MAY BE MODIFIED OR WAIVED ONLY IN A WRITTEN AGREEMENT SIGNED BY AN AUTHORIZED REPRESENTATIVE OF THE COMPANY AND ME. I AGREE TO CONFORM TO THE POLICIES, PRACTICES, AND PROCEDURES OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH POLICIES, PRACTICES, AND PROCEDURES AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver's license and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company's policy and federal, state, and local law, may be subject to urinalysis and/or bloodscreening or other medically recognized tests designed to detect the presence of alcohol or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company's policies and applicable federal, state, and local law. If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, no-solicitation, non-compete, and/or conflict of interest statement. I have not signed any employment agreement or other agreement which limits the type of job I might accept in the future, or which limits for whom I might work in the future, with any employer by whom I have been employed at any time during the past two (2) years. If a job offer is extended, my initial and continued employment will be conditioned upon execution of agreements, if appropriate, with regard to invention, patent, confidentiality and non-competition.

I certify that all the information on this application, my resume, or any supporting documents is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

I authorize the Company or its agents to confirm all statements contained in this application and/or resume as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States. I also understand this Company employs only individuals who are legally eligible to work in the United States.

BY CONSENTING, I CONFIRM ALL OF THE INFORMATION PROVIDED IS TRUE, AND THAT I HAVE READ, AND AGREE TO THE “NOTES AND TERMS.”

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Applicant's Signature:

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Date:

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Applicant's Name (please print):

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Parent/Legal Guardian Signature:

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Date:

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Witness:

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Date:

Comments

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