Application for Employment

Name *
Date *
Home Phone Number *
Home Phone Number
Cell Phone Number *
Cell Phone Number
Address *
Have you ever applied or been employed by us? *
(Per Hour)
Are you willing to work overtime if asked? *
(Evening, Weekend or Days)
Are you legally eligible to work in the United States *
Graduated *
If no, did you complete and pass the GED exam?
Have you attended college? *
(RN, LPN, etc)
Phone Number *
Phone Number
Supervisor's Name *
Supervisor's Name
Started Employment *
Started Employment
Ended Employment *
Ended Employment
Did you give notice? *
We may contact the employer you have listed above, unless you indicate otherwise. *
Have you ever plead guilty, nolo contendere (no contest), or been convicted of any crime, misdemeanor or felony, in this state or any other state, except minor traffic offenses? (Driving under the influence of drugs or alcohol is not considered a minor traffic offense.) *
To fully answer this question, you must disclose any crime for which you received a suspended imposition of sentence, whether or not you are still on probation.
Have you ever been named as a perpetrator of abuse, neglect, or exploitation of a child, elderly person, or an adult by a state or federal agency in a case wherein that an agency found probable cause to suspect, or received a court ruling or determination that substantiated the allegations against you as valid? This includes any incidents that resulted in your name being included, for any period of time, on the Employee Disqualification List maintained by the Missouri Department of Health and Senior Services, the Department of Mental Health, or the Missouri Division of Family Services. *
Are you related to any clients or employees of Covenant Care Services, LLC? *
Select "I agree" after reading the terms set forth below. *

* By selecting the "I Agree" option above and pressing "Submit" I hereby certify that the information contained in this application, and in any attachments made a part, are true and correct to the best of my knowledge and I agree to have any of the statements checked by Covenant Care Services, LLC unless I indicate to the contrary. I authorize previous employers listed in this application to provide Covenant Care Services, LLC any and all information concerning my previous employment and any pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to Covenant Care Services, LLC as well as from the use or disclosure of such information by the organization or any of its agents, employees, or representatives. I understand that I am required to be registered with the Missouri Department of Health and Senior Services Family Care Safety Registry. I understand that any misrepresentation, falsification, or material omission of information on this application, or during my interview, may result in my failure to receive an offer, or if I am hired, my dismissal from employment.