Application form – My Love and Care

Personal

Availability

Background

Education

Employment

References

Submit

Personal Information

All fields marked with * are required.

Position Applied For *

Date of Application

Full Name *

Social Security # *

Date of Birth *

Phone # *

Email *

Physical Address

Street Address *

City *

Zip Code *

Mailing address same as physical address

Background Information

Please answer honestly. Responses will not automatically disqualify you.

Previously worked at Love 'N Care? *

Yes No

When and reason

Convicted of a crime in the past 7 years? *

Yes No

Explain (dates and charges)

Conviction will not necessarily disqualify you.

Languages Spoken *

Spanish only English only Both

Emergency Contact

Name *

Relationship *

Phone *

Educational Background

Fill in what applies. Leave blank if not applicable.

School Type	Name / City	Course or Major
High School
College
Postgraduate
Business/Trade
Other

Employment History

List your last 3 employers, starting with the most recent.

Employer 1 (Most Recent)

Employer *

Phone

Address

From

Job Title

Supervisor

Starting Salary

Final Salary

Duties & Responsibilities

Reason for Leaving

Contact for Reference?

Employer 2 (Optional)

Employer

Phone

Address

From

Job Title

Supervisor

Starting Salary

Final Salary

Duties & Responsibilities

Reason for Leaving

Contact for Reference?

Employer 3 (Optional)

Employer

Phone

Address

From

Job Title

Supervisor

Starting Salary

Final Salary

Duties & Responsibilities

Reason for Leaving

Contact for Reference?

Skills, Qualifications & Comments

References (3 Required)

You must provide 3 references (not immediate family) who know your work ethic and abilities. All 3 are required.

Name *

Phone *

Years *

Relation *

Name *

Phone *

Years *

Relation *

Name *

Phone *

Years *

Relation *

Certification & Signature

Please read and agree to the following.

I certify that the facts in this application are true and complete. Misrepresentation will be cause for rejection or dismissal.

I understand my employment is not guaranteed for any term and may be terminated at any time by either party.

If employed, I agree to comply with Love 'N Care's safety, health rules, and code of conduct.

This application remains active for one year. I authorize investigation of all statements made herein.

If required, I agree to drug testing. Love 'N Care is an Equal Opportunity Employer.

Type Full Name as Signature *

Date

I have read and agree to the terms above *

✅

Application Submitted!

Thank you! Love 'N Care will review and contact you shortly.

Language

Employer 1 (Most Recent)

Employer 2 (Optional)

Employer 3 (Optional)

Application Submitted!

Application Uploaded!

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