Employment Application

Chosen Home Care Inc. · 30 Drakes Branch Drive, Pembroke NC 28372 · Phone: 910-668-1109

Fields marked * are required.

Page 1

1Applicant Information

Date of Application *

Full Name *

Phone *

Cell

SSN — last 4 digits only *Social Security Number Your full SSN will be collected in person.

Date of Birth *

Residential Address *

City/State/Zip *

Mailing address is the same as residential

Mailing Address

City/State/Zip

Driver's License #

Expiration Date

2Position

Employment Desired *

Permanent Full-time Permanent Part-time Temporary Full-time Temporary Part-time

Position Applying For *

Earliest Date Able to Begin Work

Salary Desired

Have you ever worked for the company?

Yes No

3Education

Level	Name & Address	Dates Attended & Degree Received
High School
College
Graduate
Other

Special Training or Volunteer Work in the area of employment desired

4Background

Have you ever been convicted of a Felony? *

Yes No

Describe (if you answered yes above)

Have you lived outside of NC in the past 5 years? *

Yes No

If yes, fingerprints will be required prior to beginning employment.

Page 2

If yes, do you have a North Carolina Driver's License?

Yes No

5Employment History

Must be completed with dates entirely or this application will be dismissed.

Employer 1

Company Name *

Phone

Contact Name

Contact Phone

Employed From (MM/YYYY) *

To (MM/YYYY) *

Position Held

Salary Paid

Last Worked

Reason for Leaving

Employer 2

Company Name

Phone

Contact Name

Contact Phone

Employed From (MM/YYYY)

To (MM/YYYY)

Position Held

Salary Paid

Last Worked

Reason for Leaving

Employer 3

Company Name

Phone

Contact Name

Contact Phone

Employed From (MM/YYYY)

To (MM/YYYY)

Position Held

Salary Paid

Last Worked

Reason for Leaving

6References

Please provide as much information as possible.

Reference 1

Name *

Address

Phone Number *

Relationship

Years Known

Reference 2

Name

Address

Phone Number

Relationship

Years Known

7Certification

I certify that the information in this application is true and complete to the best of my knowledge. *

Signature (type your full name) *

Date *