Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap, veteran status, marital status, sexual orientation, or any other characteristic protected by law. We are an equal opportunity employer.
Do you have experience working in home care?
If so, was experience gained working for an agency? (List job in prior employment):
If so, was experience gained working for an
individual? (List name, address, phone in prior employment):
Employment History
Please list chronologically, beginning with most recent experience.
Employer 1:
Address/City:
Date From:
Date To:
Supervisor:
Telephone:
Salary:
Type of Work:
Reason For Leaving:
Employer 2:
Address/City:
Date From:
Date To:
Supervisor:
Telephone:
Salary:
Type of Work:
Reason For Leaving:
Employer 3:
Address/City:
Date From:
Date To:
Supervisor:
Telephone:
Salary:
Type of Work:
Reason For Leaving:
Education
Name &
Location of School
Select Last Year Completed
Major
Course
Diploma/Degree
High School
College/University
College/University
Business or Trade School
Other Training
Homemaking
Date
City, State
Personal Care Homemaking
Date
City, State
Home Health Aide
Date
City, State
Companion
Date
City, State
Chore
Date
City, State
Certified Nursing Assistance
Date
City, State
Supportive Home Care Aide
Date
City, State
Medical Assistant
Date
City, State
MAP Training/Other Medication Management
Date
City, State
Human Service Provider Mental Health Worker
Date
City, State
Personal Information
Are you legally authorized to work in the U.S.?: (If hired, you will be required to provide proof of work authorization.)
Are you at least 18 years of age?:
Briefly describe skills you may have that you acquired in other employment or armed forces:
Have you ever been convicted of a crime (felony)?:
If yes, give details: (Convictions are not automatic bar to employment)
Do you have any other skills you wish to mention?:
Are you presently employed?:
If so, may we contact your present employer?:
If hired, when would you be available?:
Employment References
List individuals familiar with your job qualifications (No relatives or personal friends).
1) Name of Reference:
2) Name of Reference
Occupation:
Occupation:
Address:
Address:
City/State/Zip:
City/State/Zip:
Phone:
Phone:
Relationship:
Relationship:
How Long Known:
How Long Known:
How Were You Referred To This Job:
Please read carefully before submitting your application
All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired. I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment. I understand that upon receiving a job offer, a physical examination and drug screening may be required. Note: If this is a job requirement, you will be notified.
Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company's unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other that an officer or official of the company, and then only by means of a signed written document. We have a policy of no smoking on the premises.
Check this box to certify that you have read and accept the above statement.
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Note: You will receive a copy of your employment application via the e-mail address entered above.
Please note that all contact information will be kept confidential
and will not be sold or released.
(Please see our Privacy Policy for more information.)
Do you have experience working in home care? 
Please list chronologically, beginning with most recent experience.
