Employment Applications

Please complete the following application for all Aides positions. At the bottom of the page, click the Send button. Your application will be carefully reviewed by a member of our Human Resource Department.


Licensed Application – CNA, HHA, STNA

Are you 18 years old?*


General Information

Last Name*

First Name*

Middle Initial

Maiden Name

Qualifications
 CNA HHA STNA

Type / License #

Issued by State of

Exp Date

Address*

City*

State*

Zip*

Phone*

Cell Phone

Email*

Will you work in a home with a dog, cat, bird or other pet?

If No, state kind of pet you WILL NOT work with:

Do you have the ability to travel from home to home?*

Do you have access to a car?

Do you have a driver's license?

What counties are you willing to travel?*
Ctrl(Cmd) + Click to Select Multiple

Cincinnati Area

Dayton Area

Columbus Area

Toledo Area

Have you ever been convicted of a criminal offense other than a traffic violation?*

If Yes, please explain

Have you ever been employed by any division of Home Care by Black Stone?*

If so, when?

How were you referred to Home Care by Black Stone?

Name of Referral

Please list any languages in which you are fluent:


Availability

Are you available to work weekends?*

What days / hours are you available to work?

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to

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Education / Experience

High School Name

High School City / State

Graduated?

High School Degree

College Name

College City / State

Graduated?

College Degree

Other Name

Other City / State

Graduated?

Other Degree

Skills Inventory A

Skills Inventory B


Previous Employment

List your last 5 employers, both permanent and temporary.

1. Employer Name

Position

Supervisor

Pay Rate

From:
To:

Reason for Leaving

2. Employer Name

Position

Supervisor

Pay Rate

From:
To:

Reason for Leaving

3. Employer Name

Position

Supervisor

Pay Rate

From:
To:

Reason for Leaving

4. Employer Name

Position

Supervisor

Pay Rate

From:
To:

Reason for Leaving

5. Employer Name

Position

Supervisor

Pay Rate

From:
To:

Reason for Leaving


Personal References

No family members please.

1. Name

Phone

Address

City

State

Zip

Occupation

Relationship

Years Known

2. Name

Phone

Address

City

State

Zip

Occupation

Relationship

Years Known

3. Name

Phone

Address

City

State

Zip

Occupation

Relationship

Years Known


Validated Information

 

I certify that the answers given herein are true and complete to the best of my knowledge.

 

I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.*

 

I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision.

 

I understand that if I am offered employment, I will be working for Assisted Care by Black Stone, on its payroll, at its clients' premises.*

 

I understand that my employment may be terminated by Assisted Care by Black Stone at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination.*

By typing your full name in the box below, you are stating that all details given in the above application are true. Your typed name represents your digital signature.

Signature*

Signature Date*