Applications

Companion Services in Covington, Georgia

    APPLICANT INFORMATION

    Name:
    Last 4 digits of SSN:
    Address:
    Street:
    City:
    State:
    Zip Code:
    Phone:
    Email:
    Years’ Experience:
    Ethnicity:
    Gender:MF
    Date of Birth:

    EMERGENCY CONTACT

    Name:
    Relationship:ParentSiblingRelativeOther
    Address:
    Employer:
    Phone:
    Phone type:WorkHomePagerCell

    #2

    Name:
    Relationship:ParentSiblingRelativeOther
    Address:
    Employer:
    Phone:
    Phone type:WorkHomePagerCell

    MEDICAL INFORMATION

    Allergies:YesNoOther
    Seizures:YesNoOther
    Medical Diagnosis:
    Present Prescribed Meds/Dosage/Frequency:
    Adaptive Equipment:
    Hospital Preference:
    Pharmacy:
    Other:
    Private Insurance:YesNo
    If yes, Name:
    Policy#:
    Policy Coverage:

    EMPLOYMENT ELIGIBILITY

    Name:
    Social Security Number:
    Address:
    Phone Number:
    Are you eligible to work in the UnitedStates?YesNo
    Have you been convicted of or plead no contest to a felony within the last five years?YesNo
    If so explain:
    Position applied for:
    What date are you available to start work?
    Days Available:SunMonTuesWedThFriSat
    Hours Available From:
    Hours Available To:

    EDUCATION

    Name and Address of School 1#:
    Major Degree/Diploma 1#:
    Graduation Date 1#:
    Name and Address of School 2#:
    Major Degree/Diploma 2#:
    Graduation Date 2#:
    Name and Address of School 3#:
    Major Degree/Diploma 3#:
    Graduation Date 3#:

    SKILLS AND QUALIFICATIONS

    EMPLOYMENT HISTORY

    ALL APPLICANTS MUST PROVIDE A 5YR WORK HISTORY

    Employer:
    Supervisor:
    Address:
    Phone:
    Responsibilities:
    Position From:
    Position To:
    Salary:
    Reason for leaving:

    #2

    Employer:
    Supervisor:
    Address:
    Phone:
    Responsibilities:
    Position From:
    Position To:
    Salary:
    Reason for leaving:

    #3

    Employer:
    Supervisor:
    Address:
    Phone:
    Responsibilities:
    Position From:
    Position To:
    Salary:
    Reason for leaving:
    May we contact your presentEmployer?YesNo

    REFERENCES

    I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorized verification of any or all information listed above.

    Signature*
    Date