Careers - Active Assisted Living Community

Application

Step 1 of 8

12%

1. Applicant Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:(Required)

(Primary contact number)

Email Address:(Required)

(Valid email for correspondence)

Date of Birth:(Required)

MM slash DD slash YYYY

2. Position and Licensure Details

Position(s) Applying For:(Required)

Administrative

Personal Care Aide

Registered Medication Aide

CNA / Certified Nurse Aide

Registered Nurse

Licensed Practical Nurse

Licensure Information:(Required)

(For positions that require a license, such as Medication Aide, CNA, RN, or LPN)

License Number:(Required)

State of Issue:(Required)

(State in which the license is held)

License Expiration Date:(Required)

MM slash DD slash YYYY

3. Availability

Date Available to Start:(Required)

MM slash DD slash YYYY

(When the candidate can begin employment)

Preferred Work Schedule:(Required)

(Days and hours the applicant is available, e.g., “Monday–Friday, 8 AM–5 PM”)

Type of Employment Desired:(Required)

(Full-Time, Part-Time, Temporary)

4. Employment History

Recent Relevant Employment: (Include positions in healthcare, assisted living, or administrative roles)

Employer Name:(Required)

Job Title:(Required)

Dates of Employment:(Required)

(From – To)

Key Responsibilities:(Required)

(Brief description of duties)
You may allow space for listing multiple positions if needed.

5. Education and Certifications

Highest Level of Education Completed:(Required)

(e.g., High School Diploma, Associate Degree, Bachelor’s Degree)

Relevant Certifications:(Required)

(e.g., CPR, First Aid, or any state-specific credentials)

6. References

Professional References: (Typically two are required)

Reference #1:

Name(Required)

Relationship(Required)

Phone Number(Required)

Email Address(Required)

Reference #2:

Name(Required)

Relationship(Required)

Phone Number(Required)

Email Address(Required)

7. Additional Information

Additional Skills or Comments:

(A section where you can share can share any extra details or relevant experiences that support their application)

8. Signature Section

Electronic Signature or Typed Full Name:

(As an acknowledgment)

Date:(Required)

MM slash DD slash YYYY

Certification(Required)

I certify that all information provided in this application is true and accurate to the best of my knowledge. I understand that any false or misleading information may result in the denial of my application or termination of employment if discovered later.

Comments

This field is for validation purposes and should be left unchanged.

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Email Address

Location

Phone Number

Application

1. Applicant Information

2. Position and Licensure Details

3. Availability

4. Employment History

5. Education and Certifications

6. References

Reference #1:

Reference #2:

7. Additional Information

8. Signature Section

Quick Links

I-CARE Family Of Services

Work Hours