Employment Application 1 2 3 PERSONAL INFORMATIONHave you ever used another name?*YesNoIf yes, please list hereSocial Security Number*CA Driver's License or CA ID Number*Check if not issued in CaliforniaName as it appears on your social security card*Street Address*City*State*Zip*Home PhoneCell Phone*Email* How did you hear about us? If you have been referred by an employee of Community Care on Palm, please list their names(s) here.Are you at least 18 years of age?*YesNoLisa any languages other than English that you can speak fluentlyRN, LVN, CNA, or other license or certification numberType of licenseCNARNLVNOtherExpiration date of the above license or certificationDo you require any accommodations to perform the essential functions for the position for which you are applying?*YesNoCan you travel if a job requires it?YesNoIf you are not a U.S. citizen, do you have the legal right to remain permanently and work in the U.S.?*YesNo EMPLOYMENT DESIREDPosition You Are Applying For*Shift(s) You Can Work Days Evenings Nights Any On Call Date you can start*I am applying for: Full Time Part Time EDUCATIONHighest level of education you have completed? Include RN, LVN, CNA, or other trade school.Please write "no" if not applicable.Name of last school attended? Include RN, LVN, CNA, or other trade school.Please write "no" if not applicable.Degree or certification attained?Please write "no" if not applicable.Vocational or trade training?Please write "no" if not applicable.Do you have friends or relatives working for Community Care on Palm? If so, list them here or state "none". WORK EXPERIENCE List below your work experience, starting with your present or last place of employment.EMPLOYMENT #1Name of CompanyDates of EmploymentStart DateEnd dateEnd DateWork PerformedStreet AddressCityStateZipPhoneSupervisor's NamePosition HeldReason for LeavingEMPLOYMENT #2Name of CompanyDates of EmploymentStart DateEnd DateEnd DateWork PerformedStreet AddressCityStateZipPhoneSupervisor's NamePosition HeldReason for LeavingEMPLOYMENT #3Name of CompanyDates of EmploymentStart DateEnd DateEnd DateWork PerformedStreet AddressCityStateZipPhoneSupervisor's NamePosition HeldReason for LeavingPlease explain any gaps in your employment, other than those due to personal illness, injury or disability*Have you ever been fired or asked to resign from a job? If yes, please explainIf you have never been fired, please state "no".Certification StatementI certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions, or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either expressed or implied, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.ResumeAccepted file types: pdf, doc, docx.Please attach your resume here.I understand that Community Care on Palm conducts a job-related background check. A comprehensive background check may consist of prior employment verification, professional reference checks, education confirmation, and/or criminal record and credit checks. Third-party services may be hired to perform these checks.Electronic SignatureCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.