Sustaining Life Caregivers LLC

Waterbury, Connecticut

Contact Human Resources by phone: 203-670-8218

Employment Application – Patient Care Assistant (PCA)

Sustaining Life Caregivers LLC is an Equal Opportunity Employer. Please complete all sections fully and accurately.

1. Personal Information

Full Legal Name: ______________________________________________

Address: _______________________________________________________

City/State/Zip: _________________________________________________

Phone Number: _________________________________________________

Email Address: _________________________________________________

Date of Birth: _________________________________________________

Are you legally authorized to work in the U.S.?  ☐ Yes   ☐ No

Have you ever worked for this company before?  ☐ Yes   ☐ No

If yes, when? _________________________________________________

2. Position Information

Position Applying For: Patient Care Assistant (PCA)

Full-Time ☐    Part-Time ☐    Per Diem ☐

Available Start Date: _________________________________________

Days Available: ________________________________________________

Shift Preference: ☐ Days  ☐ Evenings  ☐ Nights  ☐ Weekends

Do you have reliable transportation? ☐ Yes   ☐ No

Have you had a recent TB-negative test done? Can you provide a copy?

3. Certifications & Skills

CPR Certified? ☐ Yes   ☐ No   Expiration Date: _______________

First Aid Certified? ☐ Yes   ☐ No   Expiration Date: _________

Driver’s License Number & State: ________________________________

Do you have prior home care experience? ☐ Yes   ☐ No

If yes, please describe: _______________________________________

_______________________________________________________________

4. Employment History (Most Recent First)

Employer Name: _________________________________________________

Position: ______________________________________________________

Dates Employed: ________________________________________________

Supervisor Name & Phone: _______________________________________

Reason for Leaving: _____________________________________________

_______________________________________________________________

(Attach additional pages if necessary.)

5. Professional References

Reference Name: ________________________________________________

Relationship: _________________________________________________

Phone Number: _________________________________________________

Email: _________________________________________________________

6. Applicant Statement & Agreement

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that falsification of information may result in disqualification or termination of employment.

I understand that employment with Sustaining Life Caregivers LLC is at-will and may be terminated at any time by either party.

Applicant Signature: __________________________________________

Printed Name: _________________________________________________Date: __________________________