* = Required Information
Employment Positions
RN
LPN
CNA
HHA
PCA
  Other  
Yes No
Yes No
Yes No
$
Yes No
Yes No
Personal Information:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
EDUCATION:
EMPLOYMENT HISTORY:
Current and/or Previous Employment:
Yes No
Yes No
REFERENCES:
List 3 Work Related References
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection or dismissal Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without cause, and with or without any prior notice. I hereby agree that, as a condition of employment by the Agency, I will promptly inform the Agency in writing of any criminal convictions, in any jurisdiction (including all pleas of guilty), other than minor traffic offenses, of which I am convicted after today.
AFFIRMATIVE ACTION SURVEY
ULTIMATE CARE GROUP INC. is an Equal Employment Opportunity/ Affirmative Action Employer. In order to meet the requirements of EEO/AA we need the following information. Government agencies require reports on the sex, ethnicity, handicapped and veteran of applicants. This data is for analysis and affirmative action only. Submission of information about a handicap is voluntary. Applicants are considered for all positions and contractors are treated without regard to race, religion, sex, national origin, age, marital or veteran status, sexual orientation, medical condition or handicap. As an agency, we comply with government regulations and affirmative action responsibilities. This data is for periodic government reporting and will be kept in a confidential file separate from the application or contract.
Alaskan Native
American Indian
Black/Non-Hispanic
Hispanic
White
Vietnam Veteran
Disable Veteran
Handicapped
Male
Female
Security code