ONLINE APPLICATION

PERSONAL INFORMATION

• Last Name
  

• First Name
  

• Middle Name
  

• Address
  

• City
  

• State
  

• Zip Code
  

• Nursing/CNA License #, if applicable
  

• Are you legally authorized to work in the US?
  YesNo
  (Identity and employment eligibility will be verified as required by law.)

• Birth Date
  

• Social Security Number
  

• Home Telephone Number
  

• Cell Phone / Pager Number
  

• Email Address
  

EMPLOYMENT INFORMATION

• Position Desired
  

• Part TimeFull Time

• Shift Preference
  Day shiftNight ShiftLive-InOther

•  
  

• Do you possess a valid driver’s license?
  YesNo

• Driver’s License #
  

• Do you have your own transportation?
  YesNo

• Have you applied here before?
  YesNo

• If so, when?
  

• How were you referred to us? (Please complete one)
  Classified ad ?An agency employee ?Other ?

Where did you see ad?


Please give us their name


Please tell us

QUALIFICATIONS & EXPERIENCE

• High School
  

• Did You Graduate?
  YesNo

• College
  

• Did You Graduate?
  YesNo

• Nursing School
  

• Did You Graduate?
  YesNo

• Technical Training
  

• Did You Graduate?
  YesNo

• Languages spoken in addition to English
  

• Can you perform all of the job-related functions of the position(s) for which you are applying?
  YesNo

  If no, please explain:
  

• Do you have current CPR certification?
  YesNo

• Expiration Date
  

• Why do you want to work with Complete Care Strategies?
  

CURRENT/PAST EMPLOYMENT HISTORY

Current Employer:

• Name
  

• Address
  

• City
  

• State
  

• Zip Code
  

• Phone:
  

• Position:
  

• Date Started
  

• May we contact?:
  YesNo

• Salary/Wage
  

• Supervisor
  

Past Employers:

• Name
  

• Address
  

• City
  

• State
  

• Zip Code
  

• Phone:
  

• Position:
  

• Salary/Wage
  

• May we contact?:
  YesNo

• Supervisor
  

• Date Started
  

• Date Ended
  

• Reason for leaving
  

• Name
  

• Address
  

• City
  

• State
  

• Zip Code
  

• Phone:
  

• Position:
  

• Salary/Wage
  

• May we contact?:
  YesNo

• Supervisor
  

• Date Started
  

• Date Ended
  

• Reason for leaving
  

CRIMINAL BACKGROUND INQUIRY

• Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime?
  YesNo

• If yes, please explain
  
  (You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied or prohibited as mandated by the state of Pennsylvania.)

EMERGENCY CONTACT

• Name
  

• Home Phone
  

• Work Phone
  

• Address
  

• Relationship to you
  

• “I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.”

  CCS is an EOE and provides services without regard to race, color, national origin, sex, religion, age and disability

• Signature
  

• Date