Miss Bell’s Assisted Living Careers Careers Form Personal InformationPosition DesiredCertifications & LicensureWork EligibilityWork ExperienceEducation and TrainingSkills ChecklistBackground InformationReferencesAdditional InformationAcknowledgements Personal InformationFull NamePreferred NameDate of BirthPhone NumberEmailAddressAddress Line 1Address Line 2CityStateZip CodePreviousNextPosition DesiredPosition Applying For– Select –PCA (Personal Care Aide)CNA (Certified Nursing Assistant)Medication Technician (Med Tech)AvailabilityFull-TimePart-TimePRN (As Needed)WeekendsNightsHolidaysPreferred ShiftDayEveningNightLive-in (if applicable)PreviousNextCertifications & LicensureCertification Type PCA Certificate CNA License Med Tech CertificationPreviousNextWork EligibilityAre you legally eligible to work in the United States? Yes NoWill you require sponsorship now or in the future? Yes NoPreviousNextWork Experience Repeater Container Facility/Agency Name Supervisor Name Position Title Supervisor Phone/Email Employment Dates (From MM/YYYY to MM/YYYY) Reason for Leaving Duties/Responsibilities PreviousNextEducation and TrainingHighest Level of Education Completed– Select –High SchoolGEDAssociate DegreeBachelor’s DegreeOther (specify)OtherAdditional Training (CPR, First Aid, Dementia Care, etc.)PreviousNextSkills ChecklistSkills Checklist – Check all that applyBathing & Dressing AssistanceToileting/Incontinence CareMedication AdministrationBlood Pressure MonitoringDiabetes ManagementDementia/Alzheimer’s CareMobility Assistance / TransfersFeeding AssistanceHospice/End-of-Life CareCharting/DocumentationPreviousNextBackground InformationHave you ever been convicted of a felony? Yes NoIf yes, please explainHave you ever been listed on the NC Health Care Personnel Registry with a substantiated finding? Yes NoConsent to Background Check Yes NoConsent to Drug Screening Yes NoPreviousNextReferencesProfessional Reference 1NameRelationshipPhone/MobileEmailProfessional Reference 2NameRelationshipPhone/MobileEmailPreviousNextAdditional InformationAre you able to perform the essential functions of this job with or without reasonable accommodation? Yes NoHow did you hear about us?– Select –ReferralIndeedWebsiteFacebookFlyerOtherOtherUpload ResumeChoose File PreviousNextAcknowledgementsFull NameDate / Time I certify that the information provided is true and complete to the best of my knowledge. I understand that misrepresentation may result in my disqualification or termination if hired. Previous Submit Form