Employment Application Job Applying For: * NIGHT SHIFT CAREGIVER CAREGIVER Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### MUST HAVE PRIOR TO EMPLOYMENT: Maryland COMAR Staff Training Certificate * Yes No Maryland COMAR Cognitive Impairment Training Certificate * Yes No Background Check * Yes No 3 Reference Letter * Yes No Health Clearance Statement from a Health Care Provider * Yes No Certified Medication Technician verified by the Maryland Board of Nursing * Yes No Negative TB Test Verification * Yes No MMRV Vaccine Verification * Yes No CPR/First Aid Certification * Yes No Certified Nursing Assistant verified by the Maryland Board of Nursing * Yes No Caregiver with Delegating Nurse Competency * Yes No Prior Experience in a small assisted living facility * Yes No Availability Date * MM DD YYYY Are you a citizen of the United States? * Yes No Have you ever worked for this company? * Yes No Have you ever been convicted of a felony? * Yes No How did you hear about us? INDEED Facebook Other Thank you!
