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Applicant Information

First Name

Last Name

Phone Number

Email Address

Address

City

State

Zip Code

SSN (Last 4 Digits)

Date of Birth

Gender

Employment Informarion

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Do you have reliable transportation to and from work?

Yes No

On what date can you start working if you are hired?

Salary Desired

Are you fully vaccinated and maintain up to date status per DPH & CMS Covid 19 guidelines?

Yes No

Vaccination Card

Other Medical Documentation

Have you completed dementia training?

Yes No

Have you completed TB Screening?

Yes No

How did you hear about us?

Please provide 2 personal and professional references

Personal Information

Are you 18 years of age or older?

Yes No

Are you a member of the Armed Services?

Yes No

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes No

Are you a U.S. citizens?

Yes No

Are you legal to work in the U.S.

Applicant Signature

Agreement

The relationship between you and the Marmelade Tender Care Inc is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Marmelade Tender Care Inc. No representative of Marmelade Tender Care Inc has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature

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