Apply for Certified Medication Aide

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Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	Certified Medication Aide
ID:	Med Aide 1/24
Department:	Client Services
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Opt-In Confirmation
	I authorize recruiters from Empowering Abilities to send text messages from 8882706983 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Resume:	Supported formats: Word, PDF, RTF, Text, and HTML.

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Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

Education Requirement

* Do you have a High School diploma or GED?

	Yes
	No

Driving

Add questionnaire for any position that involves driving.

* Are you willing to drive your own vehicle and be reimbursed for mileage?

	Yes
	No

* Are you able to meet the requirement of valid driver's license?

	Yes
	No

* Are you able to meet the requirement of valid car insurance?

	Yes
	No

Availability

Please fill in your availability on the below days. For example: 7:00am-5:00pm.

* Monday

* Tuesday

* Wednesday

* Thursday

* Friday

* Saturday

* Sunday

Application for Employment

PERSONAL INFORMATION

* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes No

* Have you ever worked for this Company before?:

Yes No

If Yes, please provide details (Where/When/Job Title):

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes No

If no, please explain:

EMPLOYMENT DESIRED

* When would you be available to begin work?:

* Type of employment desired:

Full-Time
Part Time
Seasonal

* Hourly rate/salary desired:

* Are you currently employed?:

Yes No

If so may we inquire of your present employer?:

Yes No

If presently employed, why are you considering leaving?:

EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
	Yes No
	Yes No
	Yes No

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

EMPLOYER 1

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

EMPLOYER 2

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

EMPLOYER 3

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

REFERENCES Please provide three references (not relatives).

Name	Relationship	Phone Number	Email

AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date:

Application

* Do you have a record of founded child or dependent adult abuse?

	Yes
	No

* Have you ever been convicted of a crime in this state or any other state?
Note: Conviction of a crime will not necessarily disqualify an applicant from employment.

	Yes
	No

Will you be able to meet requirements on the Federal Mandate for the COVID-19 vaccine? (Answer not required):

	Yes
	No

* Have you ever been discharged or disciplined for performance-related reasons?

	Yes
	No

* Have you ever been discharged or disciplined for attendance or tardiness?

	Yes
	No

* Have you ever been discharged or disciplined for fighting, assault or related offenses?

	Yes
	No

* Have you ever been discharged or disciplined for theft, unauthorized removal of company property, or related offense?

	Yes
	No

* Have you ever been discharged or disciplined for being under the influence of alcohol or drugs while on the job, or for possession, use, or abuse of alcohol or drugs on the job?

	Yes
	No

If referred by an Empowering Abilities employee, enter name here:

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