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EMPLOYMENT APPLICATION

Please fill out the form below, or download and bring a completed copy to one of our facilities.

Download Application

Employment Application

Apply to work at MLS Senior Care

Date

Name

First Last

Present Address

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

Permanent Address (If Different)

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

Home Phone Number

Cell Phone Number

Position for which You are applying

Availability

Work Location Preference(s):

Are you currently authorized to work in the United States?

Yes

Do you now, or will you in the future, require sponsorship for a work visa?

Yes

Are you over 18 years of age?

Yes

If no, when will you turn 18?

Have you ever been employed by MLS Senior Care?

Yes

If you have been previously employed by MLS Senior Care LLC, Please provide dates & position:

Names of any relatives employed by MLS Senior Care:

How did you hear about employment opportunities with MLS Senior Care?

Employment Agency

Job Fair

MLS Senior Care LLC, Website

Employee Referral

Direct Recruitment

Other

In order that we may verify prior experience, have you used another name in your previous jobs?

Yes

If Yes, give name and specify organization(s)

Section Break

List most recent experience first. Please include volunteer experience.

Name of Organization #1

Address of Organization #1

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

Phone of Organization #1

Title or Position

Name of Supervisor

Duties

Annual Salary or Hourly Rate

Dates Employed

Reason for Leaving

Can we contact Organization #1 for reference?

Yes

Name of Organization #2

Address of Organization #2

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

Phone of Organization #2

Title or Position

Name of Supervisor

Duties

Annual Salary or Hourly Rate

Dates Employed

Reason for Leaving

Can we contact Organization #1 for reference?

Yes

Name of Organization #3

Address of Organization #3

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

Phone of Organization #3

Title or Position

Name of Supervisor

Duties

Annual Salary or Hourly Rate

Dates Employed

Reason for Leaving

Can we contact Organization #1 for reference?

Yes

Section Break

In addition to current and form employers, please list two additional professional references below that we may contact:

Name

Relationship

How long known?

Company

Title

Phone

In addition to current and form employers, please list two additional professional references below that we may contact:

Name

Relationship

How long known?

Company

Title

Phone

Section Break

Name of High School

Graduate ?

Yes

Address

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

Name of College / University

Graduate ?

Yes

Type of Degree

Year

Address

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

Other - Name of School

Graduate ?

Yes

Type of Degree / Certification

Address

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

Section Break

PROFESSIONAL LICENSES, REGISTRATIONS, AND CERTIFICATES

Type of License or Certificate

Reg. Number

Expiration Date

State

PROFESSIONAL LICENSES, REGISTRATIONS, AND CERTIFICATES

Type of License or Certificate

Reg. Number

Expiration Date

State

PROFESSIONAL LICENSES, REGISTRATIONS, AND CERTIFICATES

Type of License or Certificate

Reg. Number

Expiration Date

State

Describe any special skills/traits:

Section Break

CRIMINAL RECORD

Please complete this section on prior convictions. An applicant for employment with a sealed record on file with a court (such as a juvenile record) may answer “no record” with respect to an inquiry relative to prior arrests, criminal court appearances or convictions. A criminal arrest or conviction will not necessarily be a bar to employment.

Have you been convicted of a misdemeanor (excluding a first conviction for speeding or minor traffic violations) within the last five years?

Yes

Have you ever been convicted of a felony?

Yes

If you have answered yes to either of the above questions, please provide an explanation below.

Section Break

PLEASE READ BEFORE SIGNING

I agree to the privacy policy.

I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or immediate dismissal from employment.
I authorize all persons, schools, employers and other organizations mentioned in this application to provide MLS Senior Care with any and all information requested by MLS Senior Care related to my qualifications for employment. I hereby voluntarily release MLS Senior Care and any other persons or entities from any and all liability related to the provision of such information.
I further understand that any job offer will be contingent upon satisfactory replies to background and reference checks and that information about the content and scope of such checks will be furnished to me if I make a written request for such information within a reasonable time.
I further understand that employment with MLS Senior Care may be conditioned upon the results of a medical screening examination, skills testing and my ability to provide satisfactory documentation of my U.S. citizenship or authorization to work in the U.S. within 72 hours of the commencement of my employment.
I understand that nothing in this application for employment is intended or should be construed as an offer, agreement or contract of employment.
I further understand that employment at MLS Senior Care is at-will, which means that both the employer and the employee are free to terminate the employment relationship at any time, with or without notice or cause.
If I am employed by MLS Senior Care, I agree to comply with all of its employment policies. MLS Senior Care reserves the right to change or amend policies from time to time.
No supervisor, representative or other person at MLS Senior Care has the authority to make any agreement that is contrary to the foregoing without the written approval of Diana Conner, Owner of MLS Senior Care.
This information provided to MLS Senior Care is considered current for one year only. At the end of this period, if you are still interested in employment, it may be necessary for you to reapply by filling out a new application.

Name

First Last

Date

CAPTCHA

Private Pay, Medicaid Approved EBD, IHSS, CES, SLS Waivers Accepted.

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Grand Junction

(970) 314-2993

1000 N. 9th Ave Suite 9
Grand Junction, CO 81505

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Delta

(970) 399-1001

300 Stafford Lane Suite 30225
Delta, CO 81416