Online Application

Online Application
  • POSITION (S) APPLIED FOR / LOCATION PREFERENCE:*
  • WERE YOU REFERRED BY AN EMPLOYEE OF NPI? (If so, please list referral's name here):*
  • LAST NAME:*
  • FIRST NAME:*
  • M.I.*
  • ADDRESS:*
  • CITY*
  • STATE*
  • ZIP CODE*
  • PHONE*
  • EMAIL*
  • SOCIAL SECURITY NUMBER*
  • Have you ever been employed with us before? If YES, give date*
  • DATE*
  • Are you currently employed?*
  • May we contact your present employer?*
  • Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?*(Proof of citizenship or immigration status will be required upon employment.)
  • On what date would you be available for work?*
  • Are you available to work:*
  • Shift available:*select one or more
  • We require Personal Care Workers to work some weekend hours. Are you able to meet this requirement?*
  • Are you currently on “lay off” status and subject to recall?*
  • You must be 18 years of age or over for employment as a PCW. Do you meet this requirement?*
  • Do you have a valid driver’s license?*
  • Is your driver’s license currently revoked or suspended?*
  • Have you been convicted of a felony within the last 7 years? If Yes, please explain below.*(Conviction will not necessarily disqualify an applicant from employment.)
  • IF YES EXPLAIN*further details
  • EDUCATION
  • Elementary
  • School Name*
  • Course of Study*
  • Years Completed*
  • Diploma Received*
  • High School
  • School Name*
  • Course of Study*
  • Years Completed*
  • Diploma Received?*
  • College
  • School Name*
  • Course of Study*
  • Years Completed*
  • Diploma Received?*
  • Other
  • School Name*
  • Course of Study*
  • Years Completed*
  • Diploma Received?*
  • Describe any specialized training, apprenticeship, skills-curricular activities:*
  • EMPLOYMENT EXPERIENCE
  • Start with your most present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status. Applicants must complete this section even if submitting a resume.
  • Employeer 1
  • Employer*
  • Supervisor*
  • Address*
  • Telephone*
  • Salary*
  • Employed From*
  • Employed To*
  • Job Title*
  • Description of duties*
  • Reason for leaving*
  • MAY WE CONTACT THIS EMPLOYER AS A REFERENCE?*
  • Employeer 2
  • Employeer*
  • Supervisor*
  • Address*
  • Telephone*
  • Salary*
  • Employed From*
  • Employed To*
  • Job Title*
  • Description of duties*
  • Reason for leaving*
  • MAY WE CONTACT THIS EMPLOYER AS A REFERENCE?*
  • Employeer 3
  • Employeer*
  • Supervisor*
  • Address*
  • Telephone*
  • Salary*
  • Employed From*
  • Employed To*
  • Job Title*
  • Description of duties*
  • Reason for leaving*
  • MAY WE CONTACT THIS EMPLOYER AS A REFERENCE?*
  • Employeer 4
  • Employeer*
  • Supervisor*
  • Address*
  • Phone*
  • Salary*
  • Employed From*
  • Employed To*
  • Job Title*
  • Description of Duties*
  • Reason for leaving*
  • MAY WE CONTACT THIS EMPLOYER AS A REFERENCE?*
  • OTHER JOB-RELATED EXPERIENCE
  • Some people gain job-related experience in positions other than as an employee. For instance, an accountant may gain experience as a treasurer of a civic or school organization. Please list and describe any paid or unpaid activities, honors, experience, or training that might aid you in performing the job(s) for which you have applied that have not been listed previously in this application. (You may omit any activities, honors, memberships, or other items that tend to identify your race, sex, religion, national origin, age, disability, or other personal traits that you prefer not to disclose.)
  • ADDITIONAL DETAILS:*further details
  • REFERENCES
  • Do not list former employers or relatives.
    Reference 1
  • Name*
  • Address*
  • Telephone*
  • Occupation*
  • Reference 2
  • Name*
  • Address*
  • Telephone*
  • Occupation*
  • Reference 3
  • Name*
  • Address*
  • Telephone*
  • Occupation*
  • DISCLAIMER AND SIGNATURE
  • IMPORTANT
    PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING
  • By my signature and initials, I confirm that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment, if any discovered at a later date. I agree to immediately notify the company if I should be convicted of a felony, or any crime involving dishonesty or a breach of trust while my job application is pending or during my period of employment, if hired.*
  • I authorize any person, school, current employer (except as previously noted), past employer(s), organizations name in this application form (and accompanying resume, if any), and pre-employment screening agencies, to provide the company with relevant information and opinion that may be useful to the company in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.*
  • If offered a job, I give my permission for a pre-employment drug screen and a TB Test, and I consent to the release to the company any medical information, as m may be deemed necessary by the company in judging my capability to perform the essential functions of the work for which I am applying (with or without reasonable accommodation).*
  • I understand that if my employment is terminated by the company for dishonesty, breach of trust, criminal acts, or care giver misconduct, the authorities may be notified and I may be criminally prosecuted. I also understand that, if hired, I may not hold other employment, engage in sales, investments, or other activities that create a conflict in interest with the company.*
  • I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if fired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time.*
  • I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is future understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by authorized executive of this organization.
  • Signature*Enter your full name as your signature
  • Today's Date*

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