Pre Employment Application

"*" indicates required fields

Do you have a smartphone with internet access?*

Will you be able to pass criminal background check?*

Can you pass a drug screen test if given today?*

Do you have a checking or savings account?*

Can you obtain a checking or savings account?*

High School diploma*

G.E.D*

Are you a CMA or CNA?*

If yes, which one?*

Are you a RN or LPN?*

If yes, which one?*

Who referred you to Kellie’s Sitting Service?

Are you currently working?

List other agency here:

Work Schedule: (list days: Monday, Tueseday, etc...)

Shifts:

Are you related to anyone currently working for Kellie’s Sitting Service?

Days Available to work

Hours Available to work

Work Location Area Request

Name*

Date

Address*

Street Address City State ZIP Code

Telephone number:*

Mobile number:*

Other phone number:

Work Experiences (list 3 verifiable references)

Employer

From:

To:

Supervisor

Position

Telephone number

Reason for leaving

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I understand that if my references are verified then I will be called in for a drug test and a criminal background will be done on this Pre-Employment Application.

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NO TRAINING UNTIL BANKING INFORMATION HAS BEEN RECEIVED AND IS IN HUMAN RESOURCES. All bank information must be printed, no hand written information will be accepted. The acceptable documents for verification of banking information is a voided check or printed information on bank letterhead with the account number, routing number and status (checking/saving) account.

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Also, my signature below, acknowledges that I am fully aware that in any emergency situation (hurricanes, etc.) I am required to work the schedule assigned to me.

My signature below authorizes Kellie’s Sitting Services, Inc. to obtain information on my employment history.

Signature

Date

Effective 1/21/11, Program Director, Rena’ Sanders must sign this form confirming that pay rate has been verified and discussed for potential employee.

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Pre Employment Application

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