Contact Information 

US CAREGiver Employment Application

APPLICANT NOTE
Encare, LLC is independently owned and operated 26 Lamar Circle Suite 3 Jackson, TN 38305 (731)-664-9665

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

• Please read “Applicant Note” below.
• Complete all parts of this application.
• Application will be valid for 60 days.

Applicant Note: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Personal Care Care Business. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, will result in the termination of your employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body is may be required prior to employment.

Personal Information 

Emergency Contacts:

Availability 

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

Caregiving Experience

Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Education 

Please check the highest grade level completed:

Work History 

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Most Recent Employer 

Second Most Recent Employer 

Third Most Recent Employer 

Background 

As a condition of employment, all employees must be “Bondable”.
List states and counties of residence for the past seven (7) years:

Please describe below:
(Conviction will not necessarily disqualify applicant from employment. The recency, severity, and pertinence of the conviction to the job will all be considered.)

References 

Please complete all six references (three professional/three personal). Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance. Do not include relatives.

Professional References 

Personal References 

Certification and Release 

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

By typing your name below you are electronically signing this document.

U.S. Release & Authorization for Criminal Background Check & Drug Test

Release Authorization

Authorization to Secure Consumer Investigative Report

I authorize Encare, LLC, an independently owned and operated Personal Care Services Business, to make whatever inquiries it may deem necessary in connection with my course of employment. As part of such inquiries, Employer has my permission to contact persons who may have information regarding my suitability for employment and to secure consumer reports (including investigative consumer reports).

I authorize and instruct any person or agency contacted to participate or conduct inquiries at its request, to compile information, and to furnish any information obtained as a result of such inquiries.

I further authorize Employer, in its sole discretion, to furnish copies of this authorization and my application to any person and/or consumer-reporting agency in connection with above purposes.

Authorization for Drug Screening
I consent to drug testing designed to detect the presence of alcohol or the illegal use of drugs.

Disclosure Statement

nformation contained in reports obtained by Employer in accordance with above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Employer completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing within a reasonable period of time after your application for employment is received.

I hereby acknowledge that I have read and understand the above disclosure statement.