TLC HOME CARE OF THE TWIN CITIES
1255 West Larpenteur Avenue
St. Paul, Minnesota 55113
Phone: 651-647-0017 Fax: 651-647-3423
APPLICATION FOR EMPLOYMENT
Federal and State laws prohibit discrimination in employment because of sex, race, color, religion, national origin, age, handicap, veteran status and citizenship. We are an equal opportunity employer.
What Position are you applying for?_______________________ DATE:_________________
NAME: LAST_________________________________FIRST___________________________MI
__________ DATE OF BIRTH________________________ FEMALE______ MALE______ SOCIAL SECURITY#__________________________
ADDRESS: CITY_______________________________________________
STATE_____________________ZIP CODE______________
PHONE# _(_____)______________________ OTHER#__(_____)__________________________
EMAIL ADDRESS:______________________________________________
EMERGENCY CONTACT: NAME_____________________________________________PHONE#_(_____)__________________
RELATIONSHIP________________________________ REFERRED BY___________________________________ WHERE DID YOU SEE OUR AD?_______________________________________
HAVE YOU EVER BEEN CONVICTED OF A FELONY?__________YES_________NO
IF YES GIVE DETAILS_________________________________________________________
POSITION DESIRED RN______LPN/LVN______PCA______HOMEMAKER_____OFFICE__________
DO YOU CURRENTLY HAVE A LICENSE FOR THIS POSITION? __________YES__________NO
DO YOU HAVE A CURRENT DRIVER’S LICENSE? YES_______NO_________ DO YOU HAVE A CAR?_______YES______NO
ARE YOU EMPLOYED?_________YES_________NO MAY WE CONTACT THEM?________YES______NO
HAVE YOU EVER APPLIED TO THIS COMPANY BEFORE? YES______NO_____WHEN?________
HIGH SCHOOL: YEARS ATTENDEND___________DATE GRADUATED______________DEGREE/CERTIFICATION_________________
COLLEGE: YEARS ATTENDEND___________DATE GRADUATED______________DEGREE/CERTIFICATION_________________
______________________________________________________ COLLEGE: YEARS ATTENDEND___________DATE GRADUATED______________DEGREE/CERTIFICATION_________________
ADDITIONAL TRAINING__________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
FORMER EMPLOYERS List below your last four Employers, starting with the last one first. 1) Date: From___________To___________ Name and Address of Employer ____________________________________ ____________________________________ ____________________________________ Supervisor____________________________________ Phone Number_________________ Salary: _____________________ Position:_________________________________________________________________ Reason for Leaving: ________________________________________________________________________ 2) Date: From___________To___________ Name and Address of Employer ____________________________________ ____________________________________ ____________________________________ Supervisor____________________________________ Phone Number_________________ Salary: _____________________ Position:_________________________________________________________________ Reason for Leaving: ________________________________________________________________________ 3) Date: From___________To___________ Name and Address of Employer ____________________________________ ____________________________________ ____________________________________ Supervisor____________________________________ Phone Number_________________ Salary: _____________________ Position:_________________________________________________________________ Reason for Leaving: ________________________________________________________________________ 4) Date: From___________To___________ Name and Address of Employer ____________________________________ ____________________________________ ____________________________________ Employer____________________________________ Phone Number_________________ Salary: _____________________ Position:_________________________________________________________________ Reason for Leaving: ________________________________________________________________________
LIST BELOW THE NAMES OF THREE WORK RELATED REFERENCES
1) NAME______________________________RELATIONSHIP__________________________________ ADDRESS_______________________________________________________________ PHONE NUMBER
(_____)___________ COMPANY________________________________________________________________
2) NAME______________________________RELATIONSHIP__________________________________ ADDRESS________________________________________________________________ PHONE NUMBER
(_______)____________ COMPANY_______________________________________________________________
3) NAME______________________________RELATIONSHIP__________________________________ ADDRESS_______________________________________________________________ PHONE NUMBER
(_______)______________ COMPANY_______________________________________________________________ ADDTIONAL COMMENTS:
___________________________________________________________________________________________ _____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
STREET__________________________________________________APT#________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
EDUCATION:
NAME AND LOCATION:_________________________________________________________________________________________________________________
1) NAME AND LOCATION:___________________________________________________________________________________________________
2) NAME AND LOCATION:___________________________________________________________________________________________________
REFERENCES
