Capacity Care Employment Application

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Capacity Care, Inc. Online Employment Application

Last Name
First Name
Middle Name
Maiden Name
Other Name(s)

Current Address Information
Street Address
City
State
Zip

If Current address is less than 36 months, please enter prior address
Street Address
City
State
Zip

Contact Information
Home Phone
Cell Phone
Alternate Phone
Email Address

Please check License/Certification(s)
RN LPN CMT CNA PT/OT None

Experience
Current or most recent position:
Employer Name
Address
Contact Name
Phone No.
Permission to contact	Yes No
Employed from
Last day of employment
Reason for leaving

Next most recent position:
Employer Name
Address
Contact Name
Phone No.
Permission to contact	Yes No
Employed from
Last day of employment
Reason for leaving

Next most recent position:
Employer Name
Address
Contact Name
Phone No.
Permission to contact	Yes No
Employed from
Last day of employment
Reason for leaving

Notes
Criminal Background Check and Drug Screening required for employment. Additional information and consent form will be required. Social Security Number and birth date not obtained online, but will be obtained on initial contact. No felonies or positive drug screens will be accepted. I-9 completion with proper documents is required for employment. Must be legally authorized to work in the United States. Current copy of License and/or Certification required. It will be verified. Additional written Pre-Employment Questions will be required if you are called for an interview. Must possess ability to perform functions of the job description. It is the policy of Capacity Care, Inc. not to discriminate against any employee or qualified applicant for employment or on termination of employment because of Race, Religion, sex, color, age, national origin, disability or Veterans status. Capacity Care, Inc. is an "At Will Employer".