Date: 9/03/2010

Application Form

RetireEASE Senior Services Inc.
I UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT IS "AT WILL", AND MAY BE TERMINATED BY EITHER ME OR THE EMPLOYER AT ANY TIME.  NO ONE AFFILIATED WITH THE EMPLOYER HAS MADE ANY STATEMENT THAT IS CONTRADICTORY OR INCONSISTENT WITH "AT WILL" EMPLOYMENT, NOR HAS ANYONE MADE ANY STATEMENT OR PROMISE THAT I WILL BE HIRED.  

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Office Location
Select Office Location:

Personal Information
First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - How Did You Hear About Us?
Number Question Effective Date Expiration Date
1 Please Check All That Apply (required)  
 
 
 
 
 
2 If other, please specify how you heard about us  
  N/A N/A
3 Did You Receive A Card About Employment? (required)  
  N/A N/A
4 If yes, what is the name listed on the card?  
  N/A N/A

Section 2 - General
Number Question Effective Date Expiration Date
1 Date of Application (required)  
  N/A N/A
2 What position are you applying for? (required)  
 
 
 
 
3 If other, please specify position  
  N/A N/A
4 What is your minimum starting salary? (required)  
  (Numeric Answer Only) N/A N/A
5 Have you ever been convicted of a felony/misdemeanor? (required)  
  N/A N/A
6 If yes, please provide details  
  N/A N/A
7 Do you know someone who works for us? Who (required)  
  N/A N/A
8 Have you had any traffic violations? (required)  
  N/A N/A
9 If yes, please explain (required)  
 

Section 3 - Transportation
Number Question Effective Date Expiration Date
1 Do you have your own insured reliable car? (required)  
  N/A N/A
2 What type of insurance do you have on your vehicle? (required)  
 
 
 
3 Year, Make and Model of vehicle (required)  
  N/A N/A

Section 4 - What is your work availability?
Number Question Effective Date Expiration Date
1 If yes, what hours  
  N/A N/A
1 Monday (required)  
  N/A N/A
2 If yes, what hours  
  N/A N/A
2 Tuesday (required)  
  N/A N/A
3 If yes, what hours  
  N/A N/A
3 Wednesday (required)  
  N/A N/A
4 If yes, what hours  
  N/A N/A
4 Thursday (required)  
  N/A N/A
5 Friday (required)  
  N/A N/A
5 If yes, what hours?  
  N/A N/A
6 If yes, what hours?  
  N/A N/A
6 Saturday (required)  
  N/A N/A
7 If yes, what hours?  
  N/A N/A
7 Sunday (required)  
  N/A N/A
8 How many hours per week are you hoping to work? (required)  
  (Numeric Answer Only) N/A N/A
9 What days and times are you NOT available to work? (required)  
  N/A N/A
10 Can you work weekends? (required)  
  N/A N/A
11 If no, would you make yourself available to be on call one weekend per month? (required)  
  N/A N/A
12 Can you be called at the last minute in case of emergency? (required)  
  N/A N/A
13 Do you have an email address and internet access at home? (required)  
  N/A N/A
14 Do you have your own cell phone? (required)  
  N/A N/A

Section 5 - Education
Number Question Effective Date Expiration Date
1 High School Attended (required)  
 
2 City/State and Dates Attended (required)  
  N/A N/A
3 Graduate? (required)  
  N/A N/A
4 College Attended  
  N/A N/A
5 City/State AND Dates Attended  
  N/A N/A
6 Area of Concentration (ex. business, nursing, accounting, etc)  
  N/A N/A
7 Special Skills or Courses?  
  N/A N/A
8 Highest Degree Earned  
 
 
 
 
 
9 Other  
  N/A N/A

Section 6 - Experience
Number Question Effective Date Expiration Date
1 Briefly discuss your experience with caring for the elderly (required)  
 
2 Why do you want to work with the elderly? (required)  
 
3 What will you like the least about working with the elderly? (required)  
 
4 What are some of your interests or hobbies? (required)  
 
5 Why do you believe you are well suited for the position you are applying for?  
 

Section 7 - Work History
Number Question Effective Date Expiration Date
1 May we contact your current employer? (required)  
  N/A N/A
2 Most Current Employer (required)  
 
3 Dates Worked (required)  
  N/A N/A
4 Beg/Ending Salary (required)  
  N/A N/A
5 Reason for leaving  
  N/A N/A
6 Previous Employer  
  N/A N/A
7 Dates worked  
  N/A N/A
8 Beg/Ending Salary  
  N/A N/A
9 Duties  
 
10 Reason for leaving  
  N/A N/A
11 If less than 10 years provided; please include all other employment here  
 

Section 8 - Indicate experience with seniors in the following?
Number Question Effective Date Expiration Date
2 Companionship? (required)  
  N/A N/A
3 Bathing/Dressing? (required)  
  N/A N/A
4 Grooming? (required)  
  N/A N/A
5 Incontinence/Toileting? (required)  
  N/A N/A
6 Do have experience helping with transfer assist using a gait belt or hoyer lift? (required)  
  N/A N/A
7 Are you comfortable helping with light housekeeping? (required)  
  N/A N/A
8 Laundry? (required)  
  N/A N/A
9 Do you have experience with meal planning for the elderly? (required)  
  N/A N/A
10 Grocery Shopping? (required)  
  N/A N/A
11 Cooking? (required)  
  N/A N/A
12 Do you have any experience cooking for special needs diets? (required)  
  N/A N/A
13 If yes, what type(s)?  
  N/A N/A
14 Do you have any experience with assisting a senior in and out of a vehicle? (required)  
  N/A N/A
15 Medication Reminders? (required)  
  N/A N/A
16 Do you have any experience as a Team Leader or Supervisor? (required)  
  N/A N/A
17 Alzheimers/Dementia (required)  
  N/A N/A

Section 9 - General
Number Question Effective Date Expiration Date
1 Have you ever worked in any other state other than South Carolina? (required)  
  N/A N/A
2 If yes, please list them.  
  N/A N/A
3 Have you ever been released from a job due to discipline or been fired? (required)  
  N/A N/A
4 If yes, why?  
  N/A N/A
5 Please list any reason known to you why you might not be able to perform consistently and promptly any of the job duties of the position in which you are applying. (required)  
  N/A N/A
7 We have strict non-smoking policies. If you smoke, can you go at least four hours without a cigarette? (required)  
 
 
 

Section 10 - Other References
Number Question Effective Date Expiration Date
1 Please list 5 personal references (DO NOT LIST RELATIVES). Include valid phone numbers, their relationship to you (ex. friend, co-worker, etc) and how long you have known them (required)  
 
2 List 5 Professional References: (DO NOT LIST RELATIVES) This can include people you know that hold professional positions: Pastors, Teachers, Business Owner, Managers, etc. It is not necessary that you worked for them (required)  
 



CERTIFICATION AND RELEASE: I certify that I have read and understand the application 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 misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the employer and/or its agents, including consumer reporting bureaus, to verify any 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 also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.