* = Required Information
Personal Data
Emergency Contact Information
Job Information
Clerical Other
Burn ENT Pediatrics
Detox/Drug Rehab L & D Rehab
Telemetry Post Partum MICU
Nursery Psychiatry Orthopedics
NICU Dialysis Stepdown
Mother/Baby PACU Geriatric
Oncology Recovery Room SICU
Pedi ICU Neurology Operating Room
CCU Med/Surg Open Heart
Emergency Room Other
Hospital Hospice
Nursing Home Rehab
Private Duty Assisted Living / Residential Treatment
Full-time Part-time Contract
Spanish French German Other
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Holidays available to work
Yes No

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Yes No
Yes No
Yes No

Yes No
Yes No
Yes No

Yes No
Yes No
Yes No

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Newspaper Trade Publication Job Fair/Open House
Internet Site Company Employee – Name

* I understand that I must report all accidents to my immediate supervisor and to Tender Care, Inc. - - No MATTER HOW SLIGHT.

* I also understand that I must wear all required personal protection equipment (PPE). The penalty for not wearing PPE is disciplinary action, up to and including termination.

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Tender Care, Inc. permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Tender Care, Inc. with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Tender Care, Inc. may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Tender Care, Inc., its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Tender Care, Inc., I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Tender Care, Inc. or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Tender Care, Inc., at any time, can constitute a contract of employment. No representative or agent of Tender Care, Inc., has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Tender Care, Inc. is not involved in the day-to-day supervision or decision concerning client care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Tender Care, Inc. against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.


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