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Contact / Personal Information

First Name*

Last Name*


Cell Phone*

Primary Phone*

Alternative Phone*

Please provide the best way to contact you* EmailPhone

Current Address

Street Address*



Zip Code*

How long have you lived at this address*
Less than 5 yearsMore than 5 years

Is this address your permanent address* YesNo

How did you hear about us?

How did you learn about Premier Personal Care* AdvertisementInternetEmployment AgencyPPC Employee
Other (specify)


Are you 21 years of age?* YesNo

If hired, can you provide proof of legal age?* YesNo

If an employment opportunity is offered you will be asked to show proof of identification, reliable transportation, auto insurance and work references. Will you be able to provide this information?* YesNo


What is the highest level of education you have achieved?

High School* YesNo

College* YesNo

Graduate* YesNo

Trade/Business* YesNo


Are you fluent in reading, writing or speaking Spanish* YesNo


Are you available to work* Full TimePart Time

Are you available to work night shifts* YesNo

Are you available for travel* YesNo

Hours Available* 7a-3p3p-11p11p-7aall hours

Days available* SatSunMonTuesWedThurFri

Available for weekends or occasional weekends* YesNo

Current Status

Are you currently employed?* YesNo

Position currently held?*

Background and Consent

If employment is offered would you be willing to submit to pre-employment drug screening and background check?* YesNo

Additional Comments

Please comment on any other experience, skills or qualifications you have which would be valuable to Premier Personal Care.

Premier PERSONAL Services

Family Care Connection

Phone: 615-371-0600

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