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Raising the standard in senior care.

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

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About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Schedule a Tour

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Schedule a Tour

Raising the standard in senior care.

Schedule a Tour

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

Schedule a Tour

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

×

About Us
Our Services
Community Life
Guided Solutions
Careers
Contact Us

750 NW Walnut Lane

Black and white abstract wave pattern.

A single-story brick house with large windows and a shaded porch.

A black metal railing around a brick porch with a wooden door.

Outdoor patio dining set with eight chairs on a sunny deck.

A hallway with colorful doors and light wooden flooring.

Ceiling panel designed to look like a bright blue sky with clouds.

Modern living room with gray sofas and ceiling fan.

Modern dining room with wooden table and chairs under recessed lighting.

🏠 Keep Living Home Plus – Employment Application

Thank you for your interest in joining our team! We are committed to providing the highest quality of care to our residents, and we’re excited to learn more about you.

🔹 Personal Information

Full Name:

Date of Birth:

MM slash DD slash YYYY

Phone Number:

Email Address:

Current Address:

Street Address City State / Province / Region ZIP / Postal Code Country

🔹 Position Applied For

Position Applied For

CNA (Certified Nurse Aide)

HHA (Home Health Aide)

CMA (Certified Medication Aide)

LPN (Licensed Practical Nurse)

RN (Registered Nurse)

Other

Other:

🔹 Certifications & Licenses

Please check all that apply and provide license numbers where applicable:

Add Certification Type Below

CNA | HHA | CMA | LPN | RN

Certifications & Licenses

Certification Type

State

License Number

Expiration Date

🔹 Employment History (List your most recent 3 employers)

Employer 1

Employer Name:

Position Held:

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Supervisor Name:

Phone Number:

Reason for Leaving:

Employer 2

Employer Name:

Position Held:

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Supervisor Name:

Phone Number:

Reason for Leaving:

Employer 3

Employer Name:

Position Held:

Start Date:

MM slash DD slash YYYY

End Date:

MM slash DD slash YYYY

Supervisor Name:

Phone Number:

Reason for Leaving:

🔹 References

Professional Reference #1

Full Name:

Relationship:

Phone Number:

Professional Reference #2

Full Name:

Relationship:

Phone Number:

Personal Reference

Full Name:

Relationship:

Phone Number:

🔹 Availability

What days are you available to work?

Are you available for:

Days

Evenings

Weekends

Overnights

Can you work holidays?

Yes

No

🔹 Background Check Authorization

Background Check Authorization

I hereby authorize Keep Living Home Plus and its representatives to conduct a background check and investigate all statements contained in this application. I release all parties from any liability arising from such investigations. I understand that any false or misleading information provided may result in my disqualification or termination if already employed.

Signature:

Date:

MM slash DD slash YYYY

Raising the standard in senior care.

Schedule a Tour

750 NW Walnut Lane
Topeka, KS 66617
(785) 496-9969
(785) 496-9951
administrator@keeplivinghp.com

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