* = Required Information
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Please put a check in the corresponding box to indicate times you will be available to work.
Day
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Eve
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Night
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PRN
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Yes No
Education
Please check the highest level achieved
High School Diploma or G.E.D.
Some College
Associates Degree
Undergraduate Degree
Some Graduate Courses
Master's Degree
Please indicate the high school(s) and colleges (if applicable), you have attended,
(1)
(2)
(3)
(4)
Employment History
Please list below previous employers, starting with the most recent
(1)
Employment Dates
(2)
Employment Dates
(3)
Employment Dates
Please list three references. References must be former employers or other knowledgeable persons, excluding relatives.
(1)
(2)
(3)
I verify that the statements I have made in this application are true and complete. I understand that it is a class A misdemeanor to knowingly fail to disclose my criminal history. I understand that if I am hired, any false or incomplete statements in this application will be grounds for immediate discharge. I have read and understand the following statements:

- I hereby acknowledge that I will be required to register with the Family Care Registry within 15 days of hire date if hired, which will do a complete background check for offenses which may disqualify an applicant from being hired.

- I hereby consent to a pre-employment criminal record check

- I hereby consent to a closed records check pursuant to Section 610.210 RSMo

- I hereby acknowledge that additional background checks may be conducted as well.

- I hereby acknowledge that Agape Quality Care, LLC is an At-Will Employer.

- I hereby acknowledge that this application does not constitute a promise of employment with Agape Quality Care, LLC
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