Apply Now Age With Grace Senior Care 2230 E Highland Road Highland, MI 48356 248-529-6431 Fax 248-529-3930 Application for EmploymentLast Name(Required)First Name(Required)MI(Required)Maiden NameAddress . City ZIP / Postal Code Date(Required) MM slash DD slash YYYY Phone(Required)CellEmergency contact(Required)Email(Required) Driver’s License(Required)SS#Current Auto Insurance(Required)How did you hear about us?(Required)EducationHigh School(Required)Did you graduate?(Required)College(Required)Did you graduate?(Required)Degree(Required)Other TrainingDo you have any experience working with the elderly?Do you have any experience with Alzheimer’s or Dementia?Do you have any experience providing personal care?(Required)List all days you are available to work(Required)List time of day you are available to work?(Required)Would you consider working an overnight shift?(Required)How many hours a week would you like to work?(Required)Have you ever been convicted of a felony?(Required)If yes, please explainHas your driver’s license ever been revoked or suspended?If yes, please explainPersonal References – No Family MembersName(Required)Relationship(Required)Years of Acquaintance(Required)Phone(Required)NameRelationshipYears of AcquaintancePhoneNameRelationshipYears of AcquaintancePhoneNameRelationshipYears of AcquaintancePhonePrevious EmployersCompany(Required)Phone(Required)Supervisor(Required)Job Title(Required)Dates of Employment(Required)May we contact for reference?Reason for leaving(Required)CompanyPhoneSupervisorJob TitleDates of EmploymentMay we contact for reference?Reason for leavingCompanyPhoneSupervisorJob TitleDates of EmploymentMay we contact for reference?Reason for leaving certify that my answers are true and complete to the best of my knowledge. I give permission for Age with Grace to run a background check so that I can be insured and bonded. Date MM slash DD slash YYYY
