Application for Employment
Name
*
First Name
Last Name
Birthday
*
/
Month
/
Day
Year
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Race/ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Driver License/ID
*
Social Security Number
*
Gender/Sex
Please Select
Female
Male
Other
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Are you a U.S Citizen?
*
Yes
No
Other
Certifications (CPR, CNA, RN, LPN, etc..)
Browse Files
Drag and drop files here
Choose a file
Please click on the "Browse Files" sign to add more.
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Upload photo ( Name Tag/Badge)
*
Photo
Drag and drop files here
Choose a file
Name Tag/ Badge Required
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Driver Lis/ ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back Driver Lis/ ID
*
Browse Files
Drag and drop files here
Choose a file
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Car Insurance
Photo
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Choose a file
Name Tag Required
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Please select availability:
Rows
Day Shifts (Mornings)
Day Shifts (Mid Afternoon)
Nights
Specify other
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Select the counties below you are able to service
*
Saginaw
Baycity
Midland
Gladwin
Isabella
Tuscola
Clare
Gratiot
Sanilac
Sandford
Other
Have you been vaccinated against COVID-19?
Yes, fully vaccinated
No
Partially yes (only one dose)
Other
Do You Have Transportation?
*
Yes
No
Other
Will you be providing services for a love one?
*
Yes
No
Other
Any Felony Convictions?
*
Yes
No
Other
Reference
*
Rows
Name
Title
Phone
email
Personal Reference
Professional Reference
CONFIDENTIAL: Background Check Authorization: The information contained in this application is correct to the best of my knowledge. I hereby authorize Serenity Homecare Solutions to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize Serenity Homecare Solutions to divulge any and all information, verbal or written, pertaining to me, to or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. Serenity Homecare Solutions shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth. Any question or explanations of chargers please submit below
*
Signature
*
Date
*
-
Month
-
Day
Year
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