How did you hear about us?
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Position Applied for:
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Direct Caregivers only: As part of an application for employment with Intergen Home Care Service will obtain all information from this applicant necessary for the purpose of initiating a criminal history record check under the section 124 of Public Law 105-277, including at a minimum a Finger print card.
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Referred by:
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Have you ever filed an application with Intergen?
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Yes No |
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If Yes date: // |
Have you ever been employed here before?
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Yes No |
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If Yes date: // |
| Have you ever been employed here before? |
Yes No |
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If Yes date: // |
| Type of employment desired: |
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Date Available for Work:
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//
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| May we contact you at work: |
Yes No
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Telephone: |
| May we contact your current employer? |
Yes No |
| If under 18, can you furnish a work permit? |
Yes No |
| Do you have a car available for work use? |
Yes No |
Are you legally eligible for employment in this country?
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Yes No
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Proof of legal employment status will be required upon employment |
| Have you ever been bonded? |
Yes No |
| Have you ever been convicted of a crime or violation other than a traffic infraction? |
Yes No
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A prior conviction record will not automatically disqualify you for consideration for employment |
| If Yes, please explain: |
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Education:
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| Name of Elementary School |
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• Number of years completed
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Name of High School
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| • Number of years completed |
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Name of College/University
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| • Number of years completed |
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• Degree/Diploma Obtained
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• Major Course of Study
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Name of Graduate/Professional Inst.
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| • Number of years completed |
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• Degree Diploma Obtained
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• Major Course of Study
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| Describe Specialized Training, Skills & Extracurricular Activities: |
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Certificates Aquired:
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References:
List name and telephone number of three (3) business/work references who are not related to you. If not applicable, list three (3) school or personal references that are not related to you.
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Professional Applicants: RN, LPN, PT, SLP, OT, MSW, RT Dietitian
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Foreign Languages: List Language and check the box that best describes your skill level.
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Employment History: List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experiences. Explain any gaps in employment in comments section below.
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Emloyer 1:
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Telephone Number:
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Dates Employed:
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Work Performed:
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Job Title:
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Address:
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Hr. Rate / Salary Starting
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Hr. Rate / Salary Ending
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Supervisor & Title
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Reason for Leaving
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May we contact for referrence
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Yes No Later
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Emloyer 2:
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Telephone Number:
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Dates Employed:
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Work Performed:
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Job Title:
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Address:
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Hr. Rate / Salary Starting
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Hr. Rate / Salary Ending
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Supervisor & Title
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Reason for Leaving
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May we contact for referrence
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Yes No Later
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Emloyer 3:
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Telephone Number:
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Dates Employed:
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- |
Work Performed:
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Job Title:
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Address:
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Hr. Rate / Salary Starting
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Hr. Rate / Salary Ending
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Supervisor & Title
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Reason for Leaving
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May we contact for referrence
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Yes No Later
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Uploads: Please upload the following documents
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ID
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| Social Security Card |
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| School Certificate |
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| 2 Letters of Reference |
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| Recent Physical |
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