Highest education completed:		School / institution:
Degree / diploma / field:		Graduation year:
CPR/First Aid certified?	Yes No	Expires:
Other certifications:		License/certification #:
License expiration date:

List your most recent employment first. You may attach a résumé, but please complete this section.

Employer / Location	Position	Dates	Supervisor / Phone	Reason for Leaving

Check skills you have performed or received training in:

Companionship / supervision	Bathing / grooming
Dressing / toileting	Meal preparation
Light housekeeping / laundry	Transfers / mobility assistance
Dementia support	Respite care
Medication reminders	Transportation / errands
Documentation / care notes	Hospice / end-of-life support

Please provide professional references who are not relatives.

Name	Relationship / Company	Phone / Email	Years Known

Can you perform the essential functions of the position, with or without reasonable accommodation? Yes No

Are you willing to complete required orientation, training, competency evaluation, and ongoing education? Yes No

Are you willing to follow client service plans, confidentiality requirements, infection-control practices, and agency policies? Yes No

Some assignments may involve standing, walking, bending, assisting with mobility, or other physical tasks. Ability to perform specific essential functions will be assessed for the position and reasonable accommodations will be considered as required by law.

Employment may be contingent on satisfactory completion of job-related screening required by law, regulation, payer requirements, or SterlingHaven policy. This may include identity/work authorization verification, references, criminal history clearances, exclusion checks, health screening, driving record review for driving positions, and other applicable clearances.

Previously worked for SterlingHaven?	No Yes	Dates/position:
Relatives/household members employed by SterlingHaven?	No Yes	Name/relationship:

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentation or omission may result in withdrawal of an employment offer or termination of employment, subject to applicable law.

I authorize SterlingHaven Human Services to verify information relevant to my qualifications and employment history and to contact the references I have provided. Any background report requiring separate authorization will be obtained only after the legally required disclosure and authorization process.

I understand that this application is not a contract or guarantee of employment and that employment terms are governed by applicable law and SterlingHaven policies.

Applicant signature: *		Date: *
Printed name: *		Best time to contact:

I certify the above typed name serves as my electronic signature and that I have read and agree to the statements above.