Resident Care Giver

First Name, Last Name*

Street Address*

City, State, Zip*

Phone Number*

Fax Number

Email Address*

Position Applying For*

Have you had experience working with dementia residents?*

Yes No

If so, how many years?

Preferred Shift(s)*

Day Evening Night

Shift(s) Willing to Work*

Day Evening Night

Preferred Number of Hours*

Full Time Part Time Temporary

Have you previously been employed at Quality Senior Villages?*

Yes No

Have you served in the military?*

Yes No

How did you hear about this position?*

Are you over 18 years of age?*

Yes No

Are you a US citizen?*

Yes No

If not, are you legally able to work in the U.S.?

Yes No N/A

Have you ever been convicted of a crime? If so, please list conviction(s) and date(s).*

When would you be available to start work?*

Education: Highest grade completed?*

Education: If college graduate, what was your degree/field of study (if applicable)?

Education: Other training or certifications? Please list applicable license numbers and state of license.

Education: Please list honors/extracurricular activities during school.

Education: Please list other professional organizations, honors, community involvement you feel would contribute to your job.

Personal Reference 1: Name, Address*

Personal Reference 1: Phone, Email*

Personal Reference 1: Relationship to the applicant*

Personal Reference 2: Name, Address

Personal Reference 2: Phone, Email

Personal Reference 2: Relationship to the applicant

Current or Most Recent Employer Name*

Current or Most Recent Employer Address, City, State, Zip*

Current or Most Recent Employer Contact Person & Phone Number*

Current or Most Recent Employer Contact Email*

Current or Most Recent Employer: Dates Employed (start and end).*

Current or Most Recent Employer: Reason for leaving.*

May we contact your current or most recent employer?*

I certify that the information in this application is true and complete for all practical purposes.*

By checking this box you have read and agree to this statement.

I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens.*

By checking this box you have read and agree to this statement.

Quality Senior Villages is a Equal Opportunity Employer.*

By checking this box you have read and understand the statement.

I give this facility permission to contact previous employers and personal references and release from all liability all individuals or companies providing such information.*

By checking this box you have read and agree to the statement above.

Attach Resume*

Quality Senior Villages

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