Artra Care Enterprises – Employment Application

Thank you for your interest in joining Artra Care Enterprises. This application will help us gather the necessary information to determine your eligibility for employment in compliance with Arkansas DHS and CES Waiver requirements.

Personal Information

Full Name *

Date of birth *

Phone *

Email *

SSN (last 4 digits): *

Address *

Street Address

City

State

Country

Postal code

Position & Availability

Preferred Shift(s): *

Evening

Overnight

Weekends

Position Applying For: *

Available Start Date: *

Desired Pay: *

Have you previously worked with individuals with disabilities? *

Yes

Are you legally authorized to work in the U.S.? *

Yes

Education

High School: *

Graduated? *

Yes

College/Trade School: *

Degree/Certification: *

Certifications (Attach copies if available) *

Upload your certifications here: *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 99 Files )

Work History (Most recent 3 positions)

Employer #1: *

Position: *

Supervisor: *

Date Employed: *

Phone: *

Reason for Leaving: *

Employer #2: *

Position: *

Supervisor: *

Date Employed: *

Phone:

Reason for Leaving: *

Employer #3: *

Position: *

Supervisor: *

Date Employed: *

Phone: *

Reason for Leaving: *

Background Information

Have you ever been convicted of a felony? *

Yes

If yes, explain:

Have you ever been listed on the Adult or Child Maltreatment Registry? *

Yes

Are you willing to undergo background checks and drug screening? *

Yes

References (Professional Only)

Name: *

Phone: *

Relationship: *

Years Known: *

Name: *

Phone: *

Relationship: *

Years Known: *

Emergency Contact

Name: *

Phone: *

Relationship: *

Signature & Certification

Signature

Clear

Application Date

I certify that all information provided in this application is true and complete.

I understand that false information may disqualify me from employment.

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Your information is 100% secure and will never be shared. By submitting this form, you agree to be contacted by Artra Care Enterprises regarding care services