Serenity Living Home - Suisun City, CA

Date:

Last Name:

First Name:

Middle Name:

Address (No. & Street):

City:

State:

Zip:

Phone:

Message No.:

Have you ever been employed under a different name?

Yes

No

If yes, please list all names used:

Do you possess a valid California driver’s license?

Yes

No

Has your driver’s license ever been suspended or revoked?

Yes

No

If yes, please explain:

Date of Last Physical Examination:

Date of Last TB Test:

Employment Desired:

Employment Desired:

Position Applying For:

Caregiver

Med-Tech

Cook

Housekeeping

This facility is in operation 24 hours a day, 7 days per week. What days and shifts are you available to work?

This facility is in operation 24 hours a day, 7 days per week. What days and shifts are you available to work?

Days of Week:

Shifts:

Day

Evening

Night

If hired, on what date can you start work?

Salary sought:

Personal Information:

Personal Information:

Why are you applying for this position?

If hired, do you have a reliable means of transportation to and from work?

Yes

No

Are you at least 18 years old?

Yes

No

(If under 18, hire is subject to verification that you are of minimum legal age, and certain job Residential Care Facilities, require that employees are at least 18 years old)

(If under 18, hire is subject to verification that you are of minimum legal age, and certain jobs at Residential Care Facilities require that employees are at least 18 years old.)

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

Yes

No

Please review the job description for which you are applying.

Please review the job description for which you are applying.

Are you able to perform the essential functions of the job, either with or without reasonable accommodation?

Yes

No

If No, describe the functions that cannot be performed:

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/ employee Hire is subject to passing a medical examination, and to skill and agility tests.)

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/ employees. Hire is subject to passing a medical examination, and to skill and agility tests.)

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?

Yes

No

If Yes, state the nature of the crime(s), when and where convicted and disposition of the case.

(Note: CA State Law requires us to obtain a criminal record clearance prior to employment).

(Note: CA State Law requires us to obtain a criminal record clearance prior to employment).

Are you currently employed?

Yes

No

If so, may we contact your current employer?

Yes

No

Education

Education

Circle Highest Year Completed:

Diploma:

Are you currently enrolled in a High School Completion course?

Yes

No

If Yes, give expected completion data:

High School Name:

Address:

City:

State:

Zip:

No of units completed:

Did you graduate?

Yes

No

Degree or Diploma

The Serenity Living Home

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