WebForm_NoWorriesEmployment

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No Worries is an Equal Opportunity Employer and considers all applicants for employment without regard to race, color, religion, creed,
gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. Applicants are
required to pass a national criminal history check and be prepared to work in a drug- and smoke-free work environment. All successful
applicants must notify No Worries in writing, within 24 hours, of any arrest, DUII, indictment, or conviction.

* indicates required
APPLICANT INFORMATION

Last Name *

First *

M.I.

Date *

Street Address *

Apartment/Unit #

City *

State *

ZIP *

Phone Number *

Your Email Address *

Date Available *

Desired Salary $/hour *

Position Applied for *

Are you a citizen of the United States *

Yes No

If no, are you authorized to work in the U.S. *

Yes No

Have you ever worked for this company *

Yes No

If worked for this company, when

How did you hear about No Worries *

Do you have a valid Driver's License *

Yes No

Do you have current Auto Insurance *

Yes No

Do you have a reliable vehicle *

Yes No

Have you ever been convicted of a felony *

Yes No

If yes to felony, explain

Have you ever been convicted of a crime *

Yes No

If yes to convicted of a crime, explain

Have you ever been convicted of a major traffic offence*

Yes No

If yes to conviced of a major traffic offence, explain

Have you ever had any previous involvement as a defendant in professional malpractice litigation *

Yes No

If yes to malpractice litigation, explain

EDUCATION AND FORMAL TRAINING

High School *

Address

From *

To *

Did you graduate *

Yes No

Degree

College

Address

From

Did you graduate

Yes No

Degree

Other

Address

From

Did you graduate

Yes No

Degree / Certificate

SPECIAL SKILLS AND CERTIFICATIONS

CNA License *

Yes No

Date Received

Current

Yes No

CNA License #

CPR License *

Yes No

Date Received

PCA Certificate *

Yes No

Med. Terminology *

Yes No

Record Keeping/Charting *

Yes No

Calculator *

Yes No

Spreadsheet *

Yes No

Word Processor *

Yes No

FAX *

Yes No

PC *

Yes No

Bookkeeping *

Yes No

Other Skill or Certification (please specify)

LANGUAGES SPOKEN

Please list all other languages you are fluent in (excluding english)

QUALIFACATIONS

Must be at least 18 years of age.
Ability to bend, stoop, stand for extended periods of time, and walk without difficulty and ability to climb stairs if needed.
Ability to lift 25 lbs.
Current and valid driver’s license, reliable transportation and current auto insurance.
Able to speak, read and write English fluently.
Minimum of 6 months verifiable and paid caregiving experience.

OTHER QUALIFICATIONS

Why are you interested in No Worries *

Summarize the experiance and skills you feel qualify you for this position *

REFERENCES

Please provide three references, other than your business references or family, that can certify your work habits or personal character.

Full Name *

Relationship *

Company *

Phone Number *

Address *

Full Name *

Relationship *

Company *

Phone Number *

Address *

Full Name *

Relationship *

Company *

Phone Number *

Address *

PREVIOUS EMPLOYMENT

Company *

Phone Number *

Address *

Supervisor *

Job Title *

Starting Salary $ *

Ending Salary $ *

Responsibilities *

From *

To *

Reason for Leaving *

May we contact your previous supervisor for a reference *

Yes No

Company

Phone Number

Address

Supervisor

Job Title

Starting Salary $

Ending Salary $

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference

Yes No

Company

Phone Number

Address

Supervisor

Job Title

Starting Salary $

Ending Salary $

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference

Yes No

MILITARY SERVICE

Branch

From

Rank at Discharge

Type of Discharge

If other than honorable, explain