Christian Companion Senior Care

Online Application
Please fill out this application completely

Personal Information

First Name:

Last Name:

Middle Initial:

Street Address:

City:

State:

Zip Code:

Home telephone w/ area code (XXX) XXX-XXXX

Cell phone w/ area code (XXX) XXX-XXXX

E-mail address:

__________________________________________________________________________________________________________

Employment Information

Position applying for:

Days available to work:

Sun. Mon. Tues. Wed. Thurs. Fri. Sat.

Date available to begin work:

Salary required:

Which shifts are you willing to work:

1st 2nd 3rd Rotating

Will you work weekends and/or holidays:

Weekends Holidays

Will you work overtime:

Are you 18 years of age:

Do you have reliable transportation:

Do you have a valid driver's license:

If so, DL# State Issued:

Do you have any pending criminal charges against you:

If so, Alleged Offense:
City/State Alleged Offense Occurred:
Date Alleged Offense Occurred:

Have you ever been convicted of a felony:

If yes, please complete the following:
Offense(s):
City and State:
Date Offense Occurred:
Fine or Sentence:

Are you legally able to work in the U.S. as a U.S. citizen or an alien authorized to work in the U.S.?

If applicable, type of visa:
Expiration Date of visa 00/00/0000:

__________________________________________________________________________________________________________

Education History

School Name and Location #1

Time you attended the school (year to year):

Did you graduate:

Degree earned:

Major/Subject/Hours:

School Name and Location #2

Time you attended the school (year to year):

Did you graduate:

Degree earned:

Major/Subject/Hours:

__________________________________________________________________________________________________________

Employment History

Please start with present or most recent positions

Position #1

May we contact your current employer?

Start Date and Ending Date:

Name of employer:

Address of employer including city and state:

Type of position:

Supervisor's name:

Telephone number:

Starting salary:

Ending salary:

Reason for leaving:

Position #2

Start Date and Ending Date:

Name of employer:

Address of employer including city and state:

Type of position:

Supervisor's name:

Telephone number:

Starting salary:

Ending salary:

Reason for leaving:

Position #3

Start Date and Ending Date:

Name of employer:

Address of employer including city and state:

Type of position:

Supervisor's name:

Telephone number:

Starting salary:

Ending salary:

Reason for leaving:

Position #4

Start Date and Ending Date:

Name of employer:

Address of employer including city and state:

Type of position:

Supervisor's name:

Telephone number:

Starting salary:

Ending salary:

Reason for leaving:

Have you ever been fired or asked to resign from any position?

If so, please explain:

_________________________________________________________________________________________________________

Personal References

Name and Address:

Telephone:

Name and Address:

Telephone:

Name and Address:

Telephone:

How did you hear about CCSC? Or who were you referred by? (Please be specific).

Briefly tell us about your faith and why it is important to you:

Church name:

Telephone:

Pastor:

I certify that the answers given by me in the application are true and correct without any omission of any kind. I understand that any misleading or incorrect statements may render this application void. If I am employed, and the company subsequently discovers that any answer given by me is incomplete, misleading or incorrect, I may be subject to termination. I agree that the company shall not be held liable in any respect if my employment is terminated because of false, incomplete or misleading
statements, answers, or omissions made by me in this application.

All information provided herein will be kept confidential. A pre-employment health screening is required prior to employment, which may include a DRUG SCREEN. In compliance with House Bill 2100 which requires all licensed facilities to offer only temporary employment to non-licensed new personnel, until a criminal arrest check can be completed by the Oklahoma State Bureau of Investigation. I, by signing this application give permission to perform the O.S.B.I. check and realize employment is
contingent upon results.

I also authorize pertinent companies, schools, agencies, churches or persons to give any information requested regarding my employment, character, experience and qualifications and/or suitability of employment with the company for the purpose of considering my suitability for hire or continued employment. I specifically authorize the company to conduct a criminal background check to confirm the information that I have given concerning my criminal history. I hereby forever release, discharge and
covenant not to sue any person or organization for any result of providing, obtaining or acting upon such information. I understand that such information is sought with confidentiality. In addition, a copy of this information is as valid as the original and should be recognized as such.

I understand that because this position includes spiritual ministry as a part of the job, it is a Bona Fide Occupational Qualification (BFOQ) under Title VII for caregivers to be Christians. Duties may include engaging in shared prayer time, Bible study, and other forms of spiritual encouragement. I understand that the company will encourage the personal spiritual growth of all caregivers and I agree to participate in a spiritual growth curriculum provided by Christian Companion Senior Care.

I understand and agree that if hired, my employment is for no definite period and may, regardless of the date or payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

I have read this information and agree to all stipulations within: I AGREE