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PCA/HHA Training Enrollment Application

To Applicant: We deeply appreciate your interest in our training program and assure you that we are sincerely interested in your qualifications. A clear understanding of your background will assist us in considering your application for training. Please answer ALL questions.

Personal


Personal References (Do not include relatives or former Employers)

Reference 1

Reference 2

Reference 3

State and federal laws prohibit discrimination on the basis of race, color, marital status, creed, sex, national origin, sponsor, disability, handicap, age, veteran status, or sexual preference.

Employment Record

List present and most recent positions (beginning with most recent).

Employer 1

Employer 2

Employer 3

Employer 4

Education

PCA/HHA Training Questionnaire

Please answer each question.


I understand that being accepted into the training program does not in any way constitute an offer of employment with Schofield Home Health Care Services, Inc. Successful completion of the training program may lead to a NYS approved certificate, and eligibility to apply for employment with any home care agency in New York State.