CK Home Care, Inc.
23123 Oakview Heights Drive
Fergus Falls, MN 56537
218-998-3778
Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veteran's employment.  We are an equal opportunity employer.
 
 
PERSONAL INFORMATION

NAME

PRESENT ADDRESS

PERMANENT ADDRESS

PHONE NO.                                        REFERRED BY
       
IN CASE OF EMERGENCY NOTIFY

US MILITARY OR NAVAL SERVICE                                        RANK                

PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVE

HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN MINOR TRAFFIC VIOLATIONS?

IF YES,COMPLETE DISCLOSURE OF CRIMINAL CONVICTION INFORMATION FORM.
YES        NO
YES        NO
EMPLOYMENT DESIRED

POSITION        RN        LPN        Home Maker            Home Health Aide                Staffing
                          Clerical        Personal Care Attendant           Other

DO YOU HAVE A CURRENT LICENSE FOR THIS POSITION?        YES        NO        
CURRENT CERTIFICATION?        YES        NO

HAVE YOU PASSED COMPETENCY TESTING?        YES        NO
DO YOU HAVE CERTFICATE?        YES        NO

DO YOU HAVE A CURRENT DRIVERS LICENSE?        YES        NO
CAR?             YES          NO                

ARE YOU EMPLOYED?        YES        NO
IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?                YES        NO
EDUCATION
NAME AND LOCATION OF SCHOOL
YEARS ATTENDED
DATE GRADUATED
DEGREE/CERTIFICATION





























HIGH SCHOOL


COLLEGE


ADDITIONAL TRAINING
FORMER EMPLOYERS
DATE/MONTH/YEAR
NAME/ADDRESS OF EMPLOYER
AND SUPERVISOR'S NAME
SALARY
POSITION
REASON FOR LEAVING
FROM


TO



FROM


TO



FROM


TO



REFERENCES:
GIVE THE NAMES OF THREE WORK RELATED REFERENCES
NAME
ADDRESS
COMPANY/POSITION
PHONE





















I authorize investigation of all statements contained in this application.  I understand that misrepresentation or omission of facts called for is cause for dismissal.  Further, I understand and agree that my employment is for not definite period and may regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.

I hereby agree, as a condition of employment by the agency, I will promptly inform the agency in writing of any criminal convictions, in any jurisdiction (including all pleas of guilty), other than minor traffic offenses, of which I am convicted after today.

DATE:

SIGNATURE:
DATE                                                    
SOCIAL SECURITY #
BY ?
 
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