Companion Care Solutions of NOVA, LLC

Applicant Information

What Position are you applying for?

First Name

Last Name

Address

City

State

Zip Code

Phone

Mobile

Other

Email Address

Driver License Number

Driver License State

Middle Name

Date of Birth

SSN

Experience

Previous Companion Care Experience

Organization	Telephone	Contact Person	Dates Worked	May We Contact	Ver

Professional References (do not include family or friends)

Contact Person	Telephone	Position/Title	Dates Known	Ver

Attach Resume:

Criminal History

Have you ever been convicted of any felony or misdemeanor offenses? Yes No

If yes, please describe the date and nature of the offense

Education

Colleges/Universities

Name	Location	Major	Graduate?	End Date

High School

Name	Location	Graduate?	End Date

Availability

Are you available for all hours? Yes No

Please tell us what times you are available

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
From
To

Please tell us what times you are unavailable

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
From
To

Specialized Training

Please list any additional certifications you hold

Environmental Concerns

Some of our clients have dogs, cats or other pets, or client may smoke. Please check any item below which you cannot or prefer not to tolerate.
I prefer (or cannot) work around

Smoking
Cats

Dogs
Birds

Other environmental concerns you have or comments

Transportation

Do you have dependable transportation? Yes No

Is your vehicle insured? Yes No

Vehicle Year

Vehicle Make

Vehicle Model

Additional Questions

Are you smoker? Yes No

If yes, how many cigarettes per day?

How did you hear about us

Please tell us about one of your recent Companion Care experiences.

Why do you want to be Companion Care with us?

Emergency Contact Information

Emergency Contacts

Name	Relationship	Cell Phone	Home Phone

Certification and Release

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize Companion Care Solutions of NOVA to verify any and all information contained within this application, 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 and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

Agree Yes No

Non Compete Clause

I agree not to do business directly with any individual or business entity that Companion Care Solutions of NOVA introduced to me or by entering into employment with such individuals or businesses.