Employment Application | Circle of Life

Contact Information
Name*
First Last
Primary Phone*
best number to reach you
Secondary Phone
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
How did you hear of this job?*

Employment Availability
Date available to begin work*
Full or Part Time?*
- Full Time (30-40 hrs)
- Part Time (less than 30 hrs)
Days Available?*
Select which days you are available to work.
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Please list the hours you are available to work.*
List your hours of availability by day, for example 9AM - 5:30PM. If you are not available on a particular day, leave blank. If you are available the entire day, enter ANY.
Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Employment History
List your employment record in chronological order, beginning with your current or most recent employer. If you have fewer than three past employers, complete the inapplicable fields with "N/A".
Employer 1
Company Name*
Company Location*
Dates of Employment*
From To
Position Title*
Salary
Supervisor Name*
Supervisor Phone*
Duties and Responsibilities*
Reason for leaving*
Employer 2
Company Name*
Company Location*
Dates of Employment*
From To
Position Title*
Salary
Supervisor Name*
Supervisor Phone*
Duties and Responsibilities*
Reason for leaving*
Employer 3
Company Name*
Company Location*
Dates of Employment*
From To
Position Title*
Salary
Supervisor Name*
Supervisor Phone*
Duties and Responsibilities*
Reason for leaving*

Caregiver Training
List dates attended and expiration if applicable.
Home Care Aide (HCA) / Nursing Assistant Certification (CNA) / Fundamentals of Caregiving*
Training/Certification Title Date Training Completed Date of Expiration if applicable
First Aid
Dates Attended Date of Expiration if applicable
CPR
Dates Attended Date of Expiration if applicable
HIV / Blood Borne Pathogens
Dates Attended Date of Expiration if applicable
Other
Dates Attended Date of Expiration if applicable

Other
Do you hold a valid driver license?*
- Yes
- No
Do you drive your own vehicle?*
- Yes
- No
If you answered 'No' to the previous question, what mode of transportation do you use?
e.g. bicycle, bus, rides from a friend...
Why do you want to work at CIRCLE OF LIFE and what attracts you to a caregiving position?*
Describe how you would interact with clients.*
Is there anything else you'd like to add about yourself?
By checking this box, I certify that the information contained in the application is true and correct to the best of my knowledge.*
- By checking this box, I certify that the information contained in the application is true and complete to the best of my knowledge. I understand that the withholding, misrepresentation or falsification of information shall be grounds to refuse employment, or, if employed, shall be grounds for termination. I authorize the references, schools and previous employers listed to provide Circle of Life any and all information they may possess which is pertinent to this application. I release all parties and persons listed, Circle of Life or any of its members or employees from all liability for any damage, except that resulting from misrepresentation which might result from furnishing this information. I further understand that employment is on an “at will” basis, is not guaranteed for any term, and may be terminated by the co-op or myself for any reason at any time, with or without notice.
Today's Date*

Contact Information