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If your application is incomplete or does not clearly show the experience and/or training required, your application may not be accepted. If you have no information to enter in a section, please write N/A. |\n\n| Name (First, MI, Last) |  |\n| --- | --- |\n| Mailing Address |  |\n| City, State, and Zip Code |  |\n| Telephone | Alternate Phone |\n| Are you 18 years old or older?䡩Yes 䡩No\u003Cbr>Are you 21 years old or older?䡩Yes 䡩No | Email |\n\n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| 䡩 Ihave no preference. | 䡩 Mon. | 䡩 Tues. | 䡩 Wed. | 䡩 Thurs. | 䡩 Fri. | 䡩 Sat. | 䡩Sun. |\n| I am seeking a: |  | 䡩 Full-time job |  | 䡩 Part-time job |  | 䡩 Full-or Part-time |  |\n| How many hours can you work weekly? |  |  |  | Can you work nights? |  | Date available to begin |  |\n\n| Have you ever been found to have committed abuse of an adult or child? This includes founded or substantiated abuse or neglect. | 䡩 Yes | 䡩 No |\n| --- | --- | --- |\n| Have you ever been listed on the US Health & Human Services Office of Inspector General’s Exclusions List or the US General Services Administration’s System for Award Management Exclusions List? | 䡩 Yes | 䡩 No |\n| If you answered to yes to either question above, please explain: |  |  |\n\n\n| Positions that may require driving |  |  |\n| --- | --- | --- |\n| Do you have a driver's license? Expiration 䡩 Yes 䡩 No\u003Cbr>date: | Driver's license number | Issued in what state? |\n| Have you had any motor vehicle accidents during the past three years? |  | 䡩 Yes 䡩 No If yes, how many? |\n| Have you had any traffic tickets or moving violations during the past three years? |  | 䡩 Yes 䡩 No\u003Cbr>If yes, how many? |\n\n\n| Education Name of School or College |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| School | Location (mailing address) | Years\u003Cbr>Completed | Major | Degree or\u003Cbr>Diploma |\n|  |  |  |  |  |\n\n| Please list ALL work experience beginning with your most recent job held. Attach additional sheets if necessary. |  |  |\n| --- | --- | --- |\n| Company | Name of last supervisor | Hrs/week |\n| Address | City, State, and Zip Code |  |\n| Phone number | Your last job title |  |\n| Reason for leaving (be specific) |  |  |\n| List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. |  |  |\n| May we contact this employer? 䡩 Yes 䡩 No |  |  |\n\n| Company | Name of last supervisor | Hrs/week |\n| --- | --- | --- |\n| Address | City, State, and Zip Code |  |\n| Phone number | Your last job title |  |\n| Reason for leaving (be specific) |  |  |\n| List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. |  |  |\n| May we contact this employer? 䡩 Yes 䡩 No |  |  |\n\n\n| Certifications | and Trainings |  |\n| --- | --- | --- |\n| Do you have current CPR and First Aid\u003Cbr>certifications? | 䡩 Yes 䡩 No | Expiration date: |\n| Do you have an Oregon Certified Nursing Assistant license? | 䡩 Yes 䡩 No | Expiration date: |\n| Do you currently have an approved background check or final fitness determination for the position you are currently applying for? | 䡩 Yes 䡩 No | Expiration date: |\n| Do you have a current role approval from the Multnomah County Adult Care Home Program? | 䡩 Yes 䡩 No | Expiration date: |\n| Have you completed any trainings or certifications required by the Multnomah County Adult Care Home Program? (Home and Community-Based Services, Providing Inclusive Care, Pre-Service Dementia, Mandatory Abuse Reporting, Six Rights of Safe Medication Administration, Ensuring Quality Care, Fire Safety, PreService Infection Prevention and Control for Community-Based Care, Food handlers card or other trainings) | 䡩 Yes 䡩 No | List details here: |\n\n| Please include name, phone number, and circumstances of your acquaint","cbCaihBKH3RDDBoz","https://ap.wps.com/l/cbCaihBKH3RDDBoz","pdf",129152,"English","# Employer and Applicant Information\n## Contact, Availability, and Work Preferences\n## Eligibility and Background Questions\n# Driving and Education\n## Driver’s License and Accidents\n## Education History\n# Work Experience and Certifications\n## Work Experience Details\n## Certifications and Trainings\n# References and Declarations\n## References and Authorizations\n## Applicant Signature","[{\"question\":\"What information must be provided in the applicant identity and contact section?\",\"answer\":\"The form requests the applicant’s name, mailing address, city/state/ZIP, telephone, alternate phone, email, and eligibility answers for age-related questions.\"},{\"question\":\"What scheduling and availability details are collected?\",\"answer\":\"It asks for preferred shift days, weekly working hours, whether the applicant can work nights, and the date available to begin.\"},{\"question\":\"What background and driving-related disclosures are included?\",\"answer\":\"The form includes questions about abuse/neglect findings and listings on exclusion lists, plus whether the applicant has a driver’s license and driving-related incidents or traffic violations in the past three years.\"}]","Sample Job Application - Employment Application Form | PDF"]