Employment
Employment

APPLICATION

TELL US ABOUT YOU
First Name
M. I.
Last Name
Address 1
Address 2
City
State
Zip Code
Phone #
Cell #
Email
Date Available
Are you UNDER 18? Yes     No
Do you have a legal right to work in the US? Applicants must present documentation of their legal right to work in the US prior to employment. Yes     No
Have you ever used another name? Yes     No
If YES, give names and dates:
Have you ever been an employee of Catalina? Yes     No
If YES, when and under what name:
Have you ever submitted an application here before? Yes     No
If YES, when?
Do you have any relatives employed by Catalina? Yes     No
If YES, give names and dates:
Have you ever been convicted of a crime, including misdemeanors, (regardless of number of years ago)? Yes     No
If YES, please explain:
How did you hear about us? Newspaper    Friend_Family
Website / Internet    Other
ARE YOU A...
CNA Certified Nursing Assistant (see below)    Certified Caregiver
Home Health Aid    Nursing Assistant
If CNA, State Board of Nursing Certification #:
All states where registered:
Has your license ever been suspended/revoked Yes     No
Have you been disciplined by any State Board? Yes     No
EDUCATION & TRAINING
Elementary and/or
High school:
Highest grade completed:      GED
College:
City/State:
From: To:
Did you graduate? Yes     No
Degree:
Business /
Vocational School:
City/State:
From: To:
Did you graduate? Yes     No
Degree:
Caregiver Training: On the job training
Certified Caregiver
CNA Program
Where did training occur?
When
# of Hours
EMPLOYMENT HISTORY
Company
Phone
Address
Supervisor
Responsibilities
From: To:
Reason for leaving
Company
Phone
Address
Supervisor
Responsibilities
From: To:
Reason for leaving
Company
Phone
Address
Supervisor
Responsibilities
From: To:
Reason for leaving
DISCLAIMER

In the event of employment, I agree to abide by all rules currently in effect and subsequently issued. I authorize all schools which I attended and all previous employers to furnish my record, reason for leaving, and all information they may have concerning me and I hereby release them and Catalina from all liability for any damage whatsoever arising there from. I also authorize investigation of all statements in this application. In addition, offers of employment are contingent upon satisfactory reference checks from previous and/or current employers, including Catalina, if applicable. All candidates for employment & employees with Catalina may be required to submit to and successfully complete a drug screen. This examination will screen for the presence of illegal drugs and controlled substances. Catalina will not hire any candidate or will terminate employment for anyone who refuses to be tested or who fails the test. I understand that, in the event of my employment, I shall be subject to dismissal if any of the information I have given in the application is false, misleading, or if I have failed to give any material information herein requested. I further understand that acceptance of any offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. Furthermore, I agree to reimburse this employer for their attorney fees, collection fees, costs and expenses in successfully defending any lawsuit I may assert in state or federal court based on action taken by the employer for false or misleading statements of omissions connected with this Employment Application and/or the hiring process.

If you agree to the above statement please click 'submit' below. This will be considered an electronic signature.

You will be notified ONLY if you are selected for an interview.



< Back to TOP