Mary's Loving Care Employment Application Last Name First Name Middle Address City State Home Phone Cell Phone Email Address Social Security # Are you a U.S. Citizen? YESNO Have you ever been convicted of a felony? YESNO If selected for employment are you willing to submit to a pre-employment drug screening? YESNO Education Please List all Past Education Other Training or Certificates Employment History Employer Dates Employed Work Phone Address City State Position Pay Rate Duties Supervisor's Name Reason for Leaving May We Contact Them? YESNO Employer Dates Employed Work Phone Address City State Position Pay Rate Duties Supervisor's Name Reason for Leaving May We Contact Them? YESNO Employer Dates Employed Work Phone Address City State Position Pay Rate Duties Supervisor's Name Reason for Leaving May We Contact Them? YESNO References Name Title Phone Name Title Phone Name Title Phone YES I certify that all answers given are true and complete to the best of my knowledge YES I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. YES In the event of employment, I understand that false of misleading information given in my application or interview(s) may result in discharge. Attach Resume: Electronic Signature Date All care givers and all staff, have to be licensed and they must undergo background checks before they are hired. How do we protect our elders from accidents at home? (201) 470-5355 make an appoinment