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Who We Are
Mission
Our Team
Our Services
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Careers
Staff Portal
Resident Portal
Contact Us
JobApplication
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JobApplication
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Applicant Information
Full Name:
*
First
Middle
Last
Date Of Birth:
*
Phone Number
*
Address:
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email:
*
Date Available:
Social Security #:
Desired Salary $:
Position Applied For:
Days Available:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Shift Available:
12am - 8am
8am - 4 pm
4pm - 12 am
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S?
*
Yes
No
Do you have a driver's license?
*
Yes
No
If yes, since when?
Have you ever been convicted of a felony?
*
Yes
No
If yes, explain:
*
Have you ever had a substantiated case brought against you by Child and/or Adult Protective Service?
*
Yes
No
If yes, explain:
*
Education
Certificate:
List your certificates in the field above
High School:
Address:
High School Start Date:
High School End Date:
Did you graduate?
*
Yes
No
Diploma:
College Name:
Address:
From:
To:
Did you graduate?
Yes
No
Degree:
References
Please list three professional references
Full Name:
*
First
Middle
Last
Relationship:
Company:
Phone:
*
Email address:
Full Name:
*
First
Middle
Last
Relationship:
Company:
Phone:
*
Email address:
Full Name:
*
First
Middle
Last
Relationship:
Company:
Phone:
*
Address:
Previous Employment
Company:
*
Phone:
*
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company:
*
Phone:
*
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Military Service
Branch:
From
To
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. If hired; (1) I agree to follow all rules and regulations of Coastal Community Care, LLC as they develop and change. (2) I authorize Coastal Community Care, LLC to conduct investigation on me; my background check and my performance, and I understand that the results will become a part of my employment record.
Signature:
*
Sign with your Full Name
Submit
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