Born to Care, LLC – Employment Application Born to Care, LLC Compassionate Care, Every Step of the Way 827 Big Bethel Road, Hampton, VA 23666 · (757) 323-7272 · jasminepotter@born-to-care.com Applicant Information Personal Details Full Name Address City State ZIP Phone Email Date Upload Résumé (PDF/DOC, optional) If your form receiver doesn't support file uploads, remove this field or capture a link to a résumé instead. Position Applying For Role & Discovery Select a Position Choose… Caregiver Lead Caregiver Medication Aide Housekeeper Other If Other, specify How did you hear about us? Availability Schedule Days Available Hours Available Full-Time Part-Time Desired Start Date Education & Certifications Schooling High School Year Completed College/Vocational Year Completed Certifications (CPR, First Aid, Medication Aide, etc.) Employment History (Last 3) Employer 1 Employer Name Job Title Dates of Employment Supervisor Name Supervisor Phone Reason for Leaving Employer 2 Employer Name Job Title Dates of Employment Supervisor Name Supervisor Phone Reason for Leaving Employer 3 Employer Name Job Title Dates of Employment Supervisor Name Supervisor Phone Reason for Leaving References Professional & Personal Professional Reference 1 – Name Phone Professional Reference 2 – Name Phone Personal Reference – Name Phone Emergency Contact Primary Contact Name Relationship Phone Alternate Phone Authorization & Declaration Consent I authorize Born to Care, LLC to contact my references, former employers, and educational institutions to obtain information about my employment and background history. I release all parties from any liability for furnishing such information. I certify that the information provided is true and complete to the best of my knowledge. I understand that false or misleading information may result in disqualification or dismissal if employed. I acknowledge that employment is contingent upon satisfactory reference and background checks. Electronic Signature (Type full name) Date Clear Submit Application By submitting this form, you consent to the storage and processing of your information for employment consideration.