Skip to content

Home
About
Services
Our Staff
Apply Online
Contact

Menu

Home
About
Services
Our Staff
Apply Online
Contact

Home
About
Services
Our Staff
Apply Online
Contact

Menu

Home
About
Services
Our Staff
Apply Online
Contact

Application for Employment

Appointment

Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
Are You a U.S. Citizen?*

YesNo
Are You Authorized to Work in The U.S.?*

YesNo
Are You 18 years or older?*

YesNo
Have You Ever Been Convicted of a Felony?*

YesNo
If selected for Employment, are you willing to Submit to a Pre-Employment Drug Screening Test?*

YesNo
Position:
Position you are Applying For:
Available Start Date:

MonthDayYear
Desired Pay:
Employment Desired:

Full TimePart TimePer Diem/ Private Duty contractor
Education:
School Name: *
Location:*
Years Attended:*
Degree Received:*
Major:*
Education 2:
School Name: *
Location:*
Years Attended:*
Degree Received:*
Major:*
Reference 1:
Name:*
Title:*
Company: *
Phone:*
Reference 2:
Name:*
Title:*
Company: *
Phone:*
Reference 3:
Name:*
Title:*
Company: *
Phone:*
Employment History:
Employer (1):
Job Title:*
Work Phone*
Employment Start Date:

MonthDayYear
Employment End Date:

MonthDayYear
Starting Pay Rate:*
Ending Pay Rate:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Skills/ Licensures:
Employer (2):
Job Title:*
Work Phone*
Employment Start Date:

MonthDayYear
Employment End Date:

MonthDayYear
Starting Pay Rate:*
Ending Pay Rate:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Skills/ Licensures:
Signature Disclaimer:

Powered by Jotform SignI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release Clear
Should be Empty:

Empowering Care, Personalized for You.
Your Family is Our Family at Affiniti Care LLC.

109 Belgrade Avenue, Aldan, PA 19018
610.-977-1045
info@afincare.org