Care Provider Background Screening Clearinghouse Education and Awareness Website- CLICK HERE Application for Employment Name(Required) First Last Social Security #(Required)Date(Required) MM slash DD slash YYYY Address(Required) Street Address City State ZIP / Postal Code Phone(Required)Secondary PhoneEmail(Required) Position DesiredWhen can you start?Desired wageAre you currently employed? Yes No If so, may we contact your current employer? Yes No Have you applied to this office before? Yes No Education HistoryHigh SchoolYears attendedDid you graduate? Yes No CollegeYears attendedSubject(s) studiedDid you graduate? Yes No Trade / Business / Correspondence School(s)Years attendedSubject(s) studiedDid you graduate? Yes No General InformationSubject of Special Study / Research WorkSpecial trainingSpecial skillsUS Military or Naval ServiceRankPrevious Employers (Most Recent First)Name & Address of EmployerTo/FromSalaryPositionReason(s) for LeavingName & Address of EmployerTo/FromSalaryPositionReason(s) for LeavingName & Address of EmployerTo/FromSalaryPositionReason(s) for Leaving