Capital Care Staffing
Employment Application
Email *
Name *
Current Address *
Phone Number and best time to contact you *
Professional License number *
Do you have an active CPR license *
Emergency Contact *
Job Position Applied for: *
Desired employment status *
Desired Salary: *
Who referred you to our company? *
Are you at least 18 years old? *
Are you willing to work any shift, including nights and weekends? If no, please state any limitations. *
If offered employment, when would you be able to start? *
Are you able to perform the essential functions of the job position you seek with or with out reasonable accommodation? what reasonable accommodation, if any would you request? *
Are you a citizen of the United States *
Have you ever been Convicted of a felony or misdemeanor? *
How Many years of experience do you have? *
List your current or most recent employment first. Including : Employer Name, Supervisors name, address, City and State, Job Duties, Reason for leaving, Dates of employment, Ending wage. *
College / University Name *
High School/GED Name *
Other training you wish to include
Please list two non-relatives who would be willing to provide you a reference including their contact information.
A copy of your responses will be emailed to the address you provided.
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