562 Watertown Avenue Suite 3   |   Waterbury, CT 06708

Employment Application

PrimeCare, Inc.
562 Watertown Avenue, Suite 3
Waterbury, CT 06708-2240


 EMPLOYMENT APPLICATION
an equal opportunity employer
PERSONAL

          
Name
(Last)
(First)		    
Address
(Street)
(Apt/Unit ##)
(City)
(State)
(Zip Code)
Email Address  
Telephone  

Are you a citizen of the United States? Yes       No

Can you provide proof of eligibility to work in the United States (that’s not expired)? Yes       No

JOB INTEREST
Position location/scheduled hours applied for (please refer to open positions list):
Have you applied and interviewed with PrimeCare, Inc. before? Yes       No       If so, which location?
Have you applied and interviewed with Community Options Residential Services, Inc. before? Yes       No
If so, which location?
Type of employment requested: Full Time Part Time Per Diem Managerial Supervisory Direct Care
Shift Availability (check all that apply): 2nd Shift     3rd Shift     1st Shift Split    Weekend
Are you currently employed? Yes       No
Have you worked for PrimeCare, Inc. in the past? Yes       No
Have you worked for or Community Options Residential Services, Inc. in the past? Yes       No
How did you hear about us? Friend Relative Internet     Name of Friend or Relative:


EDUCATION

Type of School Name and Location Number of Years Degree, Diploma, Certificate Received
High School
College or University


EMPLOYMENT HISTORY

1. Name of Employer
Address
(No. & Street)
(City)
(State)
(Zip Code)
Supervisor & Title Phone
Your Title Salary: Start End Fax
Work Performed
Employed From to Reason for Leaving Voluntary       Involuntary
2. Name of Employer
Address
(No. & Street)
(City)
(State)
(Zip Code)
Supervisor & Title Phone
Your Title Salary: Start End Fax
Work Performed
Employed From to Reason for Leaving Voluntary       Involuntary
3. Name of Employer
Address
(No. & Street)
(City)
(State)
(Zip Code)
Supervisor & Title Phone
Your Title Salary: Start End Fax
Work Performed
Employed From to Reason for Leaving Voluntary       Involuntary
4. Name of Employer
Address
(No. & Street)
(City)
(State)
(Zip Code)
Supervisor & Title Phone
Your Title Salary: Start End Fax
Work Performed
Employed From to Reason for Leaving Voluntary       Involuntary


SPECIALIZED SKILLS

EMT    CNA    PMT/CPI    CPR    Therap    Med Admin Cert   

Are you physically able to perform a two (2) person lift? Yes     No           Do you have any lifting restrictions? Yes     No 


SPECIFIC JOB REQUIREMENTS

Do you have a valid driver’s license? Yes     No           Date of Birth

State: Operator's Number: Expiration Date:

Are you over the age of 18? Yes     No

 

APPLICANT’S STATEMENT OF ACKNOWLEDGEMENT, RELEASE AND VERIFICATION
Please read carefully before signing.

I understand that I will be required to pass a DOT/PSL Drug Screen and that the Company will do Criminal, DMV and DDS Abuse and Neglect Registry record checks prior to and periodically during employment. I understand that the results of these checks in accordance with Agency and DDS policy and CT State Law may prevent the Agency from offering me a position or from retaining me as an employee if hired. With this understanding, I hereby authorize such background research and hold the Company harmless for complying with such policies or laws as may pertain.

I hereby attest that the information provided above is true to the best of my knowledge as of the time of this application. Should the information above change prior to hire or at any time during my employment, I agree to notify the Employer immediately. I understand that failure to do so will be cause for disciplinary action up to and including termination.

Signature: Date:

I certify that the answers and information given herein are true and complete to the best of my knowledge. I understand and accept that any false or misleading information given in my application, interview, or other informative medium (including but not limited to resumes, reference checks, etc.) may result in disqualification from employment consideration. In the case of employment, discovery that such false or misleading information is contained in this application may result in disciplinary action up to and including discharge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I also hereby authorize all past or present employers to release any relevant personnel information to the Company presenting them with this release. I release those employers past and present from any and all liability for such information they may provide and agree not to sue them for defamation or other claims based upon any statements they make to any representative of this Company regarding my personnel records.

I understand that this application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand, acknowledge and accept that, as allowed under Connecticut Law, any employment relationship with this organization is of an “at will” nature. The employee may resign at any time and the Employer may discharge the employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by written document, conduct or speech unless such change is specifically acknowledged in writing by an authorized executive of this organization. I also understand that “employment at will” does not waive any notice requirements for the Employee to the Employer.

I understand and accept that this agency performs pre-employment drug screening and that employment with the Agency will be contingent upon successful completion of this test. I also understand that the Agency may perform drug tests during employment as determined by agency policy at any time.

I further attest that should any of the information given in this application change for any reason either before or during employment, I will notify the Employer immediately.

Signature of Applicant: Date:

 

OPTIONAL APPLICANT EEO/AA QUESTIONNAIRE
Due to reporting requirements and regulations regarding Affirmative Action and Equal Employment Opportunity, the Company is required to make annual reports on applicant status and Workforce Composition. The following survey is designed and will be used only for this purpose. Completion of the survey is optional. Your application will not be affected due to your completion, partial completion or non-completion of this form.

All forms received will be kept in a confidential file (separate from your application records) and will be accessible only by the Director of Human Resources and President of the Company. Any changes in the information provided below should be reported to the Director of Human Resources immediately.

ANY INFORMTION YOU SUPPLY WILL BE KEPT CONFIDENTIAL INACCORDANCE WITH EEO/AA REGULATIONS. ANSWERING ANY OR ALL QUESTIONS BELOW IS OPTIONAL.

Thank you for your help.

Application Date:    
Position Applied For:    
Name: Date of Birth:
Address: City, State, Zip:
EEO Codes (Select): White
Black
Hispanic (Spanish Origin)
American Indian/Alaskan Native
Asian or Pacific Islander (Including Indian)
Other (Specify): 		Gender (Select): Male
Female


Veteran Status

Are you a disabled veteran-30% VA Compensation or discharged because of disability incurred in the line of duty: Yes     No 

Are you a Vietnam Era Veteran-180 days Active Duty between 8/15/64 and 5/7/75: Yes     No 

Certification

I hereby certify that the above information is true and correct to the best of my knowledge. I further understand that falsification of the information above may void my application with this company or result in termination of my employment if hired.

Signed: Dated: