Caregivers for Independence considers applicants without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation or any other legally protected status.

Name

Permanent Address

Have you ever been charged or convicted of a misdemeanor or felony?

YesNo

Caregivers for Independence is committed to maintaining a drug free workplace. We reserve the right to test all prospective employees. All employees are subject to random drug testing during employment, as well.

I agree to drug testing as a requirement for employment

Do you have a current driver's license?

YesNo

Do you have valid CPR/First Aid?

YesNo

Do you have a car?

YesNo

Are you currently employed?

YesNo

Do you have a H.S. Diploma or G.E.D.?

YesNo

May we contact your current employer

YesNo

Have you ever applied to CFI before?

YesNo

Have you ever signed a Non-Compete Agreement?

YesNo

Do you have relatives or friends who now or ever have worked for CFI?

YesNo

Do you have a military background?

YesNo

Do you have any objections to working weekends, Holidays or possible overtime?

YesNo

Educational History

G.E.D.

High School

College

Business/Trade School

Mention your preferable dates and time of availability

List Below Former Employers, Starting With Last One First.

May we Contact?

YesNo

May we Contact?

YesNo

May we Contact?

YesNo

May we Contact?

YesNo

What other specific experience, personal characteristics, other factors do you have that would be beneficial in working with individuals with developmental disabilities?

If you are offered employment, what salary/hourly rate would you require?

$

per

Professional Reference (1)

I, verify that I am releasing information that will be checked by CFI management and the above former employer is not held responsible for any information that is obtained through this reference check.

Professional Reference (2)

I, verify that I am releasing information that will be checked by CFI management and the above former employer is not held responsible for any information that is obtained through this reference check.

Professional Reference (3)

I, verify that I am releasing information that will be checked by CFI management and the above former employer is not held responsible for any information that is obtained through this reference check.

Application Acknowledgement

"I certify this application was completed by me and the entries contained in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation or omission of facts requested on this application may be grounds for rejection of this application or dismissal from employment regardless of when or how discovered."

"I authorize an inquiry which may provide background information concerning my character, general reputation and past work performance. I hereby authorize Caregivers for Independence to inquire and also authorize and request each former employer, educational institution, persons, police departments, governmental and law enforcement agencies to answer all questions which may legally be asked, and to release all information which may be legally sought in connection with this application for employment. I hereby release all parties from any liability or responsibility for doing so. I am willing that a photocopy of this authorization be accepted with the same authority as the original."

"I understand that, if hired, the required CPR, First Aid, and Medication Administration Courses will be offered to me at no cost. I also understand that I will not be paid for these courses as CFI is paying the appropriate officials to administer the course for me. If employment ceases at any time within the 90-day trial period, the cost of administering these courses will be deducted from my final paycheck."

"I understand and agree that if hired my employment is at "at will", that I or CFI may terminate the employment relationship at any time, for any reason, with or without notice. If hired, I agree to comply with all the rules, regulations and employment policies of Caregivers for Independence."

I hereby acknowledge that I have read the above statements and understand each and all of these statements.

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