Direct Care Worker

Although this application may be given consideration, its receipt does not imply that there are open positions or that the applicant will be employed. If you wish to submit a resume, you may attach it to this application, but in addition, you must complete this application and answer all questions, even those which relate to information on your resume. Please be sure that all of your answers on this application are complete, correct, and truthful. You should understand that any omission of relevant information, any false or misleading statement, or any failure to disclose facts which, if known, might reflect unfavorably on this application, may result in dismissal even if you are employed.

Please answer every question. You will not be considered as a candidate for a job with us until we have received this application fully completed and signed by you. This application will not be eligible for consideration more than 90 days after HCSSC receives it. If you wish to be considered for any position after that date, you must contact us to submit a new application.

HCSSC does not engage in any unlawful discriminate in hiring or employment on the basis of race, color, religion, national origin, disability, genetic information, sex, age, height, weight, marital status, or other legally protected characteristic. HCSSC reserves its right to withdraw any offer of employment at any time; similarly, the applicant has the right to withdraw this application at any time.

ENTER YOUR NAME AS IT APPEARS ON YOUR SOCIAL SECURITY CARD

List previous addresses within the United States, except military, if your address changed during the past 5 years. (Start with most recent address.)

EMPLOYMENT REQUEST

ATTENDANCE RECORD

How much time have you lost from work or school during each of the past two calendar years FOR REASONS OTHER THAN VACATION AND HOLIDAYS?

EMPLOYMENT RECORD

(Please complete your employment history even if a resume is submitted. Be sure to include all employers for whom you have worked. If you need more space, please continue on the space provided on page 5.)

Starting with PRESENT or MOST RECENT, list all previous employers. Include self-employment, summer, and part-time jobs. Account for periods of unemployment of more than 30 consecutive days by listing “unemployed” under “Employer,” and state beginning and ending dates of unemployment.

Employment 1

Employment 2

Employment 3

Employment 4

Employment 5

EDUCATION

PERSONAL INFORMATION

REFERENCES

Reference 1

Reference 2

Reference 3