Regal Care - Employment Application

Last Name *

First Name *

Email Address *

Phone Number

Address

Date of Birth

SSN (XXX-XX-XXXX)

Date You Can Start Work

Salary Desired

Do you have a High School Diploma?

Yes

No

Hours:

Full Time

Part Time

Days:

Swing

Evenings

Graveyard

Weekends

Status:

Regular

Temporary

Are you authorized to work in the U.S. on an unrestricted basis?

Yes

No

Include paid and unpaid positions.

Emergency Contact

Name

Relationship

Address

Phone

Alternate Phone

Secondary Contact Name

Relationship

Phone

Alternate Phone

Medical Restrictions

Professional References

Name

Tel No

Address

Name

Tel No

Address

List your educational background below.

Type	School Name	Degree / Certificate	Address / City / State
High School
College / University
Other

List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizational skills, etc.):

Upload Supporting Documents

Resume/CV

ID Card (Front & Back)

CPR Certification