Employment Application


  Employment Application

  • Senior Support, LLC is an equal opportunity employer that selects the best qualified applicants for the job based on job-related qualifications, without regard to race, color, religion, national origin, sex, age, disability, citizenship, sexual orientation, or veteran status.
  • No question on this application is intended to secure information to be used for such discrimination.
  • Replies to all questions are held in strictest confidence.
  • The entire application must be completed, even when accompanied by a resume.

Please call with any questions: 928-204-1459


Employment Desired:

When can you work? (specify hours you ARE available)

If hired, will you be able to provide documentation of your legal authorization to work in the United States? *


Please complete in details, beginning with more recent employment.

1. Current/Most Recent Employer

May we contact? *


High School

Did You Graduate? *

Trade School

Did You Graduate? *


Did You Graduate? *


Please check off the items where you have experience:



**Have you ever been convicted of a felony? *
** Have you ever been discharged from a job for involvement in an act of dishonesty or breech of trust, injury to a person or damage of property? *
Have you ever worked as a caregiver? *


Please provide the names of 3 business references that are not related to you. If you do not have any employment-related references, please list individuals who can comment on your work skills.

Reference #1

Reference #2

Reference #3


Please provide the name, relationship, and phone number for whom we should contact for you in the event of an emergency.


If employed, I agree that my employment shall be in accordance with company rules and regulations and any amendments thereto. Falsified statements on this application or any other violation of company rules and regulations may result in dismissal.

I understand and agree that any employment relationship shall be terminable at will at any time by either me or the company. I acknowledge that Senior Support will request, either prior to employment, and/or after employment that I undergo drug testing and a background check, and I consent and agree to such testing/reporting, now or in the future. I understand that a satisfactory result of drug testing is a condition of employment with Senior Support. I hereby authorize you to contact educational institutions and former employers or other persons or references who could provide information relating to my acceptability for potential employment at the company, and I authorize them to disclose any such information in their possession. I authorize the company to do a background investigation to verify my statements regarding education, employment history and criminal history. Senior Support reserves the right to bill the fees associated with drug screenings and background checks to any employee who chooses to end his or her employment before 30 days of active duty. No representations have been made to me or no agreements have been made with me relating to the employment by the company other than those that have been made in writing by an authorized representative of the company.

I certify that the information that I have provided in this application is complete and true to the best of my knowledge. I authorize Senior Support to verify the information that I have provided, and I authorize former employers, law enforcement agencies and others to verify such information without liability on their part. In making this application, I understand and agree that my employment at Senior Support means that both employees and Senior Support have the right to terminate employment at any time, with or without advance notice, and with or without cause.

Signature: ___________________________________________________________

Date: _________________

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