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Application For Employment

We do not discriminate on the basis of age over 40, race, sex, color, religion, national origin, disability, or any other applicable status protected by state or local law. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

Application Form

Step 1 of 6

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination base upon non-job-related information.

Job Applied For (Home Health Aide):(Required)

Today's Date:(Required)

Are you seeking:(Required)

When could you start?(Required)

Name(Required)

Telephone Number(Required)

Present Address(Required)

Are you 18 years of age or older?(Required)

(If you are hired you may be required to submit proof of age)

Social Security #(Required)

If hired can you furnish proof you are eligible to work in the U.S.?(Required)

Have you ever worked here before?(Required)

If yes, When?(Required)

Have you ever been convicted of any law violation (except a minor traffic violation)?(Required)

If yes, please explain:(Required)

Are you now or do you expect to be engaged in any other business or employment?(Required)

If yes, please explain:(Required)

Do you have a Valid Driver's license?(Required)

If yes, Driver's License Number:(Required)

State of License(Required)

Class of License:(Required)

Have you had your driver's license suspended or revoked in the last 3 years?(Required)

If yes, please explain:(Required)

Employment History

List the names of employers in consecutive order with present employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR.

Name of Employer:

Job Title:

Address

Dates of Employment

Please list start date and end date with the month and year.

Supervisor

Pay Start $

Pay Finish $

Telephone

Reason for Leaving

Name of Employer:

Job Title:

Address

Dates of Employment

Please list start date and end date with the month and year.

Supervisor

Pay Start $

Pay Finish $

Telephone

Reason for Leaving

Name of Employer:

Job Title:

Address

Dates of Employment

Please list start date and end date with the month and year.

Supervisor

Pay Start $

Pay Finish $

Telephone

Reason for Leaving

Personal References

Give 2 personal references, NOT relatives.

Name

Phone

Address

Name

Phone

Address

Professional References

Give 2 professional references.

Name of Professional Reference to Be Contacted:

Title:

Company Name:

Phone

Reason for leaving this company:

Name of Professional Reference to Be Contacted:

Title:

Company Name:

Phone

Reason for leaving this company:

Have you worked or attended school under any other name?(Required)

If yes, give names:(Required)

Are you presently employed?(Required)

If yes, please explain:(Required)

Have you ever been fired from a job or asked to resign?(Required)

If yes, please explain:(Required)

PLEASE READ EACH STATEMENT CAREFULLY BEFORE CHECKING

I have read, understand, and by my checking this box, consent to the following statements.

I certify that all information provided in the employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment may result in my dismissal if discovered at at a later date.

I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics, and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I authorize the investigation of any and of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations statements.

I understand that if I am extended an offer of employment, it may be conditioned upon my successful passing a complete pre-employment physical examination. I consent to release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post-employment drug screen as a condition of employment, if required.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

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