First Name

Last Name

Phone

Address

Apt. / Unit

City

State

Zip

I am applying for a position as a

Highest Level of Education

Are you a licensed CNA?

Yes, in North Carolina Yes, in South Carolina No

Have you ever been convicted of a misdemeanor, a felony, placed on probation, or given a suspended sentence in court? Failure to list convictions will result in immediate disqualification from the hiring process. Note that a conviction does not mean you cannot be hired.

Are there any pending felony or misdemeanor charges against you?

Discuss training or experience working with the elderly:

Please select all of the tasks you have assisted with or performed for seniors from the following list:

____

I certify that I have read and understand the application note at the top of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment.

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