PeopleCare Health Services Employee Application & References
Instructions: Complete all the questions. All information is secure and confidential. Please note that (1) hours are not guaranteed (2) PCHS conducts employee criminal background checks and practices random drug screening of employees and (3) PCHS is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, age or disability. We assure you that your opportunity for employment depends solely on applicant qualifications and opportunity.
Last Name
Your answer
Your answer
Address
Your answer
City
Your answer
Zip Code
Your answer
How long have you lived at this address?
Your answer
State
Your answer
Date of Birth
Your answer
Social Security Number
Your answer
Phone Number
Your answer
Alternative Phone Number
Your answer
Email Address
Your answer
Position for which you are applying?
Your answer
Have you ever applied with PeopleCare Health Services before?
Required
Hourly Wage Range Desired:
Your answer
Type of Employment Desired
Are you legally authorized to work in the United State?
Required
How did you hear about PeopleCare Health Services?
Your answer
Have you graduated high school?
If yes, what is the name of the high school?
Your answer
City of high school?
Your answer
State of high school?
Your answer
Number of years completed?
Your answer
Do you have a college/university degree?
If yes, what is the name of the college/university?
Your answer
City of college/university?
Your answer
State of college/university?
Your answer
Number of years complete?
Your answer
If completed, what was the degree received?
Your answer
Have you completed a business/trade/professional schoo/program?
If yes, what is the name of the business/trade/professional school/program?
Your answer
City of the business/trade/professional program/school?
Your answer
State of the business/trade/professional program/school?
Your answer
What certification did you receive?
Your answer
Have you ever been convicted of a crime?
Required
If yes, please list out the number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were commited, sentence(s) imposed, and type(s) of rehabilitation (a conviction does not necessarily preclude employment)
Your answer
Have you ever worked under a different name or alias?
Required
If yes, what was/were those name(s) and the reason(s) for doing so?
Your answer
Do you have any relatives and/or friends who work for PeopleCare Health Services?
If yes, what is/are their name(s)?
Your answer
Do you have a valid driver's license?
Driver's License Number
Your answer
State Driver's License was Issued?
Your answer
Expiration Date of Driver's License?
Your answer
Do you have active automobile insurance and can produce documentation to verify?
Have you had any automobile accidents in the past three (3) years?
If yes, how many and what was the final determination of fault?
Your answer
Have you had any moving violations in the past three (3) years?
If yes, how many and what were the nature of the violations?
Your answer
Do you have a dependable vehicle that meets all the requirements for ownership by the state?
If no, what arrangements do you have to get to/from assignments, especially as it pertains to inclement weather?
Your answer
Why are you applying for this position with PeopleCare Health Services?
Your answer
Name of first Personal Reference
Your answer
Phone Number
Your answer
Alternative Phone Number
Your answer
How long has this individual known you?
Your answer
What is their relationship to you?
Your answer
Name of second Personal Reference
Your answer
Phone Number
Your answer
Alternative Phone Number
Your answer
How long has this individual known you?
Your answer
What is their relationship to you?
Your answer
Name of first Professional/Company Reference
Your answer
Company Name
Your answer
Phone Number
Your answer
Alternative Phone Number
Your answer
Position They Hold/Held
Your answer
Name of second Professional/Company Reference
Your answer
Company Name
Your answer
Phone Number
Your answer
Alternative Phone Number
Your answer
Position They Hold/Held
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms