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Applicant Information
Driver License State

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Live-Ins - Being a Live-In means several consecutive days of care where the caregiver stays at the care recipient's home for the entire number of days.

Name Location Graduate? End Date
Name Location Major Graduate? End Date
Employer Telephone Supervisor Job Title Dates Worked May We Contact
Contact Person Telephone Position/Title Dates Known Ver
Criminal History

Skills and Preferences

Specialized Training

Additional Questions

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 Mercy Works 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.

I agree not to do business directly with any individual or business entity that Mercy Works has introduced to me or by entering into employment with such individuals or businesses.