Employment Interest Form EMPLOYMENT INTEREST Date * Full Name * Gender * Male Female Other Address * Apt# City * State * Zip Code * Phone * Email * Referred by: * Walk-In Friend/Relative Employee School Agency Availability * Weekdays Weekends Do you have a Valid Driver's License? * Yes No Do you have Car Insurance? * Yes No Have you taken any of the following training? * CNA/HCA CPR Training Nurse Delegation RN LPN None of the Above Do you have any allergies? Smoking Pets OthersOthers What other Languages do you speak other than English? (Leave Blank, if none) Describe Skills for Consideration: * (Example: Good Communication, Hoyer Lift, Patience, etc.) Reference Request Please give two (2) personal references. Please advice references to expect a phone call from HR on your behalf. Reference 1 Name and Position * (Ex: John Smith, Manager at ABC company) Reference 1 Phone Number Reference 2 Name and Position * (Ex: John Smith, Manager at ABC company) Reference 2 Phone Number DOCUMENTATION REQUIREMENTS (When asked to come into the office) • Original Social Security Card • State Certification, if any • Current Driver's License or State ID • Must Be Willing to Undergo a Criminal Background Submit
