Careers in Home Care | Legacy Haven Home Care LLC

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Employment Application BACKGROUND HISTORY If you are hired for the position of Personal Care Attendant (PCA), a background screening via the Family Care Safety Registry (FCSR) must be conducted prior to your first day of employment. Please read the following questions carefully and respond truthfully and fully. BACKGROUND CHECK FEE: $15.25

First Name *

Middle Name

Last Name *

Birth Date *

Street Address *

City *

State / County *

Postcode / ZIP *

Email Address *

Primary Phone Number *

Secondary Phone Number

Job Position Applying For *

Client's Name You Will Work For

Referred By

Previous Employer / Company

Previous Job Title

Employment Start Date

Employment End Date

Reason for Leaving

Reference Full Name

Reference Relationship

Reference Phone Number

Reference Company

Duties You Are Willing to Perform *

Availability (Days & Shifts) *

Preferred Client Gender *

Have you been charged with an offense other than a minor traffic violation? *

If Yes, Give Offense and Date for Each Crime

I give Legacy Haven Home Care LLC consent to conduct a pre-employment criminal record check *

I authorize Legacy Haven Home Care LLC to conduct a closed record check pursuant to Section 610.120, RSMo *

Additional Notes

Certification Statement *

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Compassionate Care at Home