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NOW HIRING FOR
Clovis
Caregiver
Licensed Practical Nurse (LPN)
Occupational Therapist (OT)
Physical Therapist Assistant (PTA)
Registered Nurse (RN)
Roswell
Caregiver
PRN Registered Nurse
Ruidoso
Caregiver
Tucumcari
Caregiver
Apply Today!
Location Applying For:
Clovis
Roswell
Ruidoso
Tucumcari
Position Applying For:
Caregiver
Licensed Practical Nurse (LPN)
Occupational Therapist (OT)
Physical Therapist Assistant (PTA)
PRN Registered Nurse (PRN RN)
Registered Nurse (RN)
Date
Name:
Home Phone:
Address:
City:
State:
Zip Code:
Email:
Referred by:
Date You Can Start:
Desired Wage?
Type of Employment
Full-Time
Part-Time
Either
How many hours can you work weekly?
Currently Employed?
Yes
No
If so, may we call your present employer?
Yes
No
Have You Applied with us Before?
Yes
No
If so, when?
Are you at least 18 years of age?
Yes
No
List any languages you speak in addition to English?
Are you able to work in a household with pets?
Yes
No
Can you work in a non-smoking environment?
Yes
No
Do you have reliable transportation?
Yes
No
Can you lift 50 pounds or more?
Yes
No
Do you have any special licensing or certification?
Yes
No
If yes, give details:
Highest Level of Education?
High School
Junior/Community College
University
Did You Graduate?
Yes
No
Graduation year
What days are you available to work?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Work History
List Past Employers, starting with most recent
1ST EMPLOYER
Name:
Phone:
Street Address:
City:
State:
Zip:
Contact Person:
Your Position:
Dates Worked:
Wage:
Reason for Leaving:
2ND EMPLORYER
Name:
Phone:
Street Address:
City:
State:
Zip:
Your Position:
Contact Person:
Dates Worked:
Wage:
Reason for Leaving:
3RD EMPLORYER
Name:
Phone:
Street Address:
City:
State:
Zip:
Your Position:
Contact Person:
Dates Worked:
Wage:
Reason for Leaving:
References
Do not list relatives or past employers
Name:
Business:
Phone:
Years Known:
Address:
Names:
Business:
Phone:
Years Known:
Address:
Name:
Business:
Phone:
Years Known:
Address:
Names:
Business:
Phone:
Years Known:
Address:
In Case of Emergency, Notify
Phone:
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