CAREERS

EMERGENCY CONTACT:

EDUCATION:

CERTIFICATION AND CREDENTIALS:

Please answer yes or no to all that apply and enter expiration dates of the certifications if applicable

FORMER AND CURRENT EMPLOYERS:

Employer 1:

REFERENCES:

List 3 people that are not employers or relatives that you have known for at least a year

Reference 1

Reference 2

Reference 3

APPLICANT AUTHORIZATION:

I certify that I have read and understood the information on this job application and that the answers given by me to the foregoing questions and the statements made my me, and any accompanying resume or documents are complete and true to my knowledge and belief. I understand that any false information, omission or misrepresentation of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize Mercy Home Care Services, LLC and/or its agents, including consumer reporting bureaus to verify any information including, but not limited to criminal history, elderly and child abuse history, and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. If hired, I agree to a criminal background check and to be fingerprinted. Upon termination, I authorize the release of reference information to potential employers. Also, I understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to random drug test to detect the use of illegal drugs prior to and during employment.