Candidate Information:

Date*

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell

Do you own a computer or have access to the internet daily?*

Yes
No

Email*

Other names which you have used:

Are you legally eligible to work in the United States?*

Yes
No

Are you at least 20 years of age?*

Yes
No

Have you ever been convicted of a crime (felony or misdemeanor)?*

Yes
No

If yes, please give the date, location and disposition of your case:

Emergency Contact:*

Emergency Contact Relationship:*

Emergency Contact Phone:*

Education and Training:

High School Diploma/GED?*

College Degree:

Years of Study:

Major:

Licenses or Certifications:

Issuing Authority:

License #:

Expiration Date:

Special Awards/Honors/Volunteer Experience:

Position You Are Seeking:

Specify:

Full Time
Part Time
Per-Diem

Preferred Shift:

If an offer is extended, when would you be able to start?

How did you hear about this position?

Alcohol and Drugs:

The Collinfield House has a Drug/Alcohol Free Workplace Policy. Do you drink?*

Amount/Frequency of Use:*

Have you been charged/convicted of any drug/alcohol related offenses? Please explain:

Driving Information:

Do you have a valid driver’s license:*

Yes
No

State:

License #:

Expiration Date:

Do you own a car?*

Yes
No

Do you have a clear driving record?

Vehicle Make:

Insurance Company:

Policy #:

Has your license ever been revoked/suspended?*

Yes
No

If yes, please explain:

How many moving violations in the last three years? Explain:

Candidate Statement Regarding Senior Care:

Please tell us why you want to care for Seniors:

AVAILABILITY:

Monday*

AM
PM
NOC

Tuesday*

AM
PM
NOC

Wednesday*

AM
PM
NOC

Thursday*

AM
PM
NOC

Friday*

AM
PM
NOC

Saturday*

AM
PM
NOC

Sunday*

AM
PM
NOC

Please explain:

EMPLOYMENT EXPERIENCE:

Are you presently employed?*

Yes
No

May we contact your employer?

Yes
No

Most Recent Employer:

Employer:*

Beginning Date:*

Ending Date:*

Job Title:*

Supervisor:*

Phone

Starting Salary:*

Ending Salary:*

Reason for Leaving:*

Job Duties:*

Past Employer:

Employer:

Starting Date:

Ending Date:

Job Title:

Supervisor:

Phone

Starting Salary:

Ending Salary:

Reason for Leaving:

Job Duties:

Past Employer:

Employer:

Starting Date:

Ending Date:

Job Title:

Supervisor:

Phone

Starting Salary:

Ending Salary:

Reason for Leaving:

Job Duties:

REFERENCES:

Reference 1:

Name/Company*

Email Address:*

Phone*

Type of Work:*

Relationship:*

Reference 2:

Name/Company*

Phone:*

Type of Work:*

Relationship:*

Email Address:*

Reference 3:

Name/Company:*

Email Address:*

Phone:*

Type of Work:*

Relationship:*

I hereby certify that the information I have provided above is accurate and complete. I understand and agree to allow Mom’s Best Friend/MBF Agency to verify this information. I understand that, if I provide fraudulent answers or false information in connection with my application for employment, it will constitute grounds for immediate dismissal upon discovery thereof. I give Mom’s Best Friend permission to contact any or all of my previous employers and references for full information and hereby release Mom’s Best Friend/MBF Agency from any and all liability for doing so. I understand that any offer of employment is contingent upon passing a background check and post-offer, pre-employment drug test and physical (including a background check/clearance with the Misconduct and/or Nurse Aid Registries, if applicable). I agree, if employed and in consideration of that employment, to abide by the policies and procedures of Mom’s Best Friend / MBF Agency. I acknowledge that, if hired, I will be an at-will employee, which means: 1. I may terminate my employment at any time; 2. My employment may be terminated at any time, with or without notice and with or without cause; and 3. Mom’s Best Friend / MBF Agency may suspend or demote me at any time. I further understand that no one has any authority to enter into any agreement of employment for any specified period of time, or to make any agreement contrary to the foregoing other than in a writing signed by me and the President or Vice-President of Mom’s Best Friend / MBF Agency of Austin.

Signature*

First Last

Date*

Jobs at Collinfield

Interested in a position at Collinfield House? Fill out the online application to begin the process.

Candidate Information:

Education and Training:

Alcohol and Drugs:

Driving Information:

Candidate Statement Regarding Senior Care:

AVAILABILITY:

EMPLOYMENT EXPERIENCE:

Most Recent Employer:

Past Employer:

Past Employer:

REFERENCES:

Reference 1:

Reference 2:

Reference 3: