PRE-EMPLOYMENT QUESTIONNAIRE Equal Opportunity Employer First Name Middle Name Last Name Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Phone Number Email Are you legally authorized to work in the US? -- Please Select -- Yes No Position Date Available Salary / Wages Expected Are you employed now? -- Please Select -- Yes No If so, may we inquire of your present employer? -- Please Select -- Yes No Have you ever worked for TSC? -- Please Select -- Yes No If so, where? When? How did you find out about Total Senior Care? Name of School Location / Years Attended Course / Degree Name of School Location / Years Attended Course / Degree Name of School Location / Years Attended Course / Degree Certifications & Credentials: Please check all that apply Driver's License Car Insurance State ID Card Social Security Card CPR Certification First Aid Certification CNA License LPN License RN License Therapy License Other Skills and Qualifications Dates Employer Salary Reason for Leaving Position Dates Employer Salary Reason for Leaving Position Dates Employer Salary Reason for Leaving Position Name Address Business / Title Phone / Email Years Known Name Address Business / Title Phone / Email Years Known Name Address Business / Title Phone / Email Years Known Upload your Resume Upload your Credentials Agree I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. Date Send
