Unique CareGivers, LLC IS AN EQUAL OPPORTUNITY EMPLOYER.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, disability or any other characteristic protected by Federal, State or local law or regulation. UCG facilities are tobacco free. A pre-employment drug screen may be required.

Please complete all portions of this application including additional job questions if applicable. All information given will be held in strict confidence.

  • If employed, you are required by law to show proof of eligibility to work in the USA.

Press the Submit Application button when you have completed your application

Personal Information

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip:

* Best Phone to Reach Me (ex (000) 000-0000):

Home Phone (ex (000) 000-0000):

Cell Phone (ex (000) 000-0000):

Preferred Name:

Home Email:

Work Email:

Position:

Are you at least 18 years old? Yes No

When would you be able to begin work? Immediately Within 2 weeks More than 2 weeks

What are your desired types of employment? Full Time Part Time Contract Temporary Seasonal None of the above

How many miles are you willing to travel?

* Employment Preference: Full-Time Part-Time Per Visit Baylor Other

* Available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

* Have you ever completed an application with us before? Yes No

If yes, when?

* Shift Preference (Days, Evenings or Weekends):

* Are you willing to work on holidays?

Yes No

* Are you willing to work on call?

Yes No

* Are you willing to work overtime?

Yes No

 

* Do you have any relatives employed at this company?

Yes No

If yes, who?

* Have you ever worked at UCG before?

Yes No

If yes, when?

* Have you ever been dismissed or forced to resign from any job held?

Yes No

If Yes, explain:

* Have you been convicted of Medicaid or Medicare fraud or abuse?

Yes No

* Are you authorized to work in the United States?

Yes No

Record of Employment


This section must be completed, starting with your present or last job. Include any job related military service assignments and volunteer activities. If you have more than 4 previous employers, you may attach them in your resume.

1. Current/Most Recent Employer

* Company Name:

* May we contact?

Yes No

* Telephone:

* Your Starting Position:

* Your Last Position:

* Months In Last Position:

* Address:

* City:

* State:

* Zip:

* Dates Employed (include Month & Year):

From To (ex: MM/YY)

* Rate of Pay:

Start End

* Supervisor's Name & Title:

* Reason For Leaving:

* Your Duties:

2. Next Previous Employer

* Company Name:

* May we contact?

Yes No

* Telephone:

* Your Starting Position:

* Your Last Position:

* Months In Last Position:

* Address:

* City:

* State:

* Zip:

* Dates Employed (include Month & Year):

From To (ex: MM/YY)

* Rate of Pay:

Start End

* Supervisor's Name & Title:

* Reason For Leaving:

* Your Duties:

3. Next Previous Employer

Company Name:

May we contact?

Yes No

Telephone:

Your Starting Position:

Your Last Position:

Months In Last Position:

Address:

City:

State:

Zip:

Dates Employed (include Month & Year):

From To (ex: MM/YY)

Rate of Pay:

Start End

Supervisor's Name & Title:

Reason For Leaving:

Your Duties:

4. Next Previous Employer

Company Name:

May we contact?

Yes No

Telephone:

Your Starting Position:

Your Last Position:

Months In Last Position:

Address:

City:

State:

Zip:

Dates Employed (include Month & Year):

From To (ex: MM/YY)

Rate of Pay:

Start End

Supervisor's Name & Title:

Reason For Leaving:

Your Duties:

Additional Questions

Explain any gaps in your employment as set forth above:

Additional Employment Information:

Please enter all your current certifications and licenses:

N/A

Year Original License:

Certificate Number:

Exp Date:

State of License or Certification:

Has your license or certification ever been revoked, suspended or denied in any states? Yes No

If yes, what state:

Is your license or certification currently under investigation? Yes No

If yes, please explain:

Education

High School / GED

* School Name:

* Last Year Completed:

1 2 3 4

* Did you Graduate?

Yes No

* Degree/Certificate:

College/Technical School

School Name:

Major/Courses:

Last Year Completed:

1 2 3 4

Did you Graduate?

Yes No

Degree/Certificate:

Graduate Studies

School Name:

Major/Courses:

Last Year Completed:

1 2 3 4

Did you Graduate?

Yes No

Degree/Certificate:

Other (specify)

School Name:

Major/Courses:

Last Year Completed:

1 2 3 4

Did you Graduate?

Yes No

Degree/Certificate:

References


Please list work references (other than friends/relatives) in section below.

Work Reference #1:

* Name:

* Company:

* Job Title:

Address:

Telephone:

Email Address:

Work Reference #2:

* Name:

* Company:

* Job Title:

Address:

Telephone:

Email Address:

Work Reference #3:

* Name:

* Company:

* Job Title:

Address:

Telephone:

Email Address:

Other Information

* Have you ever been convicted of, pled guilty or no contest to, a misdemeanor (last 3 years) or felony (last 7 years), other than minor traffic violations? A conviction is not an automatic disqualification for employment.
Yes No

If Yes, please give the date(s) and details:

* Have you ever been in the Military Service?
Yes No

If Yes, give type of discharge:

NOTE: A dishonorable or general discharge is not an absolute bar to employment.

Resume

Cover Letter and/or Text Resume:

Attach Resume - OPTIONAL:

Fair Credit Reporting Act

DISCLOSURE

As an applicant for employment with Unique CareGivers, LLC, you have rights under the Fair Credit Reporting Act (FCRA). By this document, Unique CareGivers, LLC discloses to you that a consumer report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment, if you are hired. If Unique CareGivers, LLC obtains a consumer report about you, and if Unique CareGivers, LLC considers any information in the consumer report when making an employment related decision that directly and adversely affects you, Unique CareGivers, LLC will provide you with a copy of the consumer report and a summary of your rights under the FCRA before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA.

AUTHORIZATION

By submitting this application, I acknowledge that I have received the foregoing disclosure that Unique CareGivers, LLC may obtain a consumer report as part of its pre-employment background investigation and/or during the course of my employment, if I am hired. By submitting this application, I voluntarily authorize Unique CareGivers, LLC to obtain consumer reports about me and to consider the consumer report in its pre-employment background investigation and/or when making decisions during the course of my employment, if I am hired. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

Employment Disclosure

I certify that my answers herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that any false, misleading, or incomplete information given during my application or interview(s) may result in denial of employment or in the termination of employment. I authorize Unique CareGivers, LLC to check my references and to verify information contained on this application. Further, I authorize my former employers, personal references and others to give my information concerning me requested by Unique CareGivers, LLC, whether or not it is in their records, and I hereby release them from any liability whatsoever.

I understand that if I receive an offer of employment, I may be required to take a drug screen and/or physical abilities test. I understand that the offer and my continued employment may be contingent upon completed references, successful completion of these and any other required post-offer screens, and that I am required to abide by all rules and regulations of the employer. This application for employment shall remain active for 6 months.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Unique CareGivers, LLC is of an “at will” nature, which means that I may resign at any time and Unique CareGivers, LLC may discharge me at any time with or without cause. I further understand that this “at will” employment relationship may not be changed by any written document or by conduct unless an authorized executive of Unique CareGivers, LLC specifically acknowledges such change in writing.

I understand that by applying for a position that requires me to drive more than 50% of the time, I am subject to a DMV check and may not be eligible for hire if I have four or more active points on my driver’s license as a result of traffice violations.

I understand that my employment may be contingent upon the receipt of an acceptable criminal history check received with my authorization. I understand that I may not be eligible for employment if I have had a felony conviction within the previous seven years and/or misdemeanor conviction in the previous three years involving violence, theft, and/or sexual misconduct.


* Signature (print your name):

* Date

 

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