Employment Form

    PERSONAL INFORMATION

    Name*

    Date

    Address*

    Home Phone Number*

    Social Security Number*

    Driver’s License / ID*

    State*

    Date of Birth*

    Email Address*

    Have you ever applied for employment with this Agency?

    How many hours a week are you available for work?

    Are you legally eligible for employment in the United States?

    How did you learn of our organization?

    Are you willing to work?

    Position applying for

    Educational Background

    School Name / Location

    Major

    Yrs of Study/Degree

    College / Graduate

    Vo-Tech / Trade

    High School

    Others

    EMPLOYMENT

    List the last five years employment history, starting with the most recent employer.

    1. Company Name

    Telephone

    Address

    Dates of Employment

    Starting Pay

    Ending Pay

    Job Title and Describe Work Completed

    Reason for leaving

    2. Company Name

    Telephone

    Address

    Dates of Employment

    Starting Pay

    Ending Pay

    Job Title and Describe Work Completed

    Reason for leaving

    3. Company Name

    Telephone

    Address

    Dates of Employment

    Starting Pay

    Ending Pay

    Job Title and Describe Work Completed

    Reason for leaving

    Was your last name different from your present name during the above listed jobs?

    If yes, what was your name?

    Are you currently employed?

    Do you have reliable transportation / the ability to reach multiple clients?

    TWO (2) Professional / Personal Reference Check

    1. Reference

    Full Name*

    Phone*

    City*

    State*

    If Professional Reference: Position Held

    2. Reference

    Full Name*

    Phone*

    City*

    State*

    If Professional Reference: Position Held

    GENERAL

    Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

    Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full

    Are you capable of performing the job set forth in the job description?

    If you answered No, which job requirement can you not meet?

    List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

    CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENTOPERATED

    I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

    I, authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

    I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

    This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time

    Signature*

    Date*

    Upload Documents

    SSN*

    Driving License*

    License and/or Certification*

    CPR/First Aide*

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