* = Required Information

General Information
State
Are you over 18? YesNo
Do you have a Driver's License? YesNo
Do you own a car? YesNo
What shifts would you prefer?
Days Nights PM Live-in
What license do you currently hold? CNA's PCA's RN's Others
Please specify
Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? YesNo
If yes, please explain
When the incident happened?
Employment History 1
Employer * City *
Address * State *
  Zip Code *
Start Date * End Date *
Yes No
Character References *
Employment History 2
Employer * City *
Address * State *
  Zip Code *
Start Date * End Date *
Yes No
Character References *
Employment History 3
Employer * City *
Address * State *
  Zip Code *
Start Date * End Date *
Yes No
Character References *

How did you hear about us?
Reference Release Form
I, * , hereby authorize Carolina Care Solutions and its

agents to make investigations and inquires into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities provided on my employment application. Furthermore, I authorize the company and its agents to release any reference information to prospective employers who request such information for purposes of evaluating my credentials and qualifications.

I acknowledge that I have read this authorization and release, fully understand it, and voluntarily agree to its provisions.

Signature  Date 
Printed Name