ANSWER ALL QUESTIONS COMPLETELY
(ONLY FULLY COMPLETED APPLICATIONS WILL BE PROCESSED)
Name*: SS# :
Address : City* :
Zip : E-Mail* :
Home Phone* : Alternate Phone :
Fax : Position Applied For* :
Do you have prior experience in Home Health?
Yes No
If hired, you must be at least 18 years old and show proof of age and employment authorization (right to work in the U.S.)
Will you accept :
Part-time (31 hours/week or less) Full-time (32 hours/week or more)
Can you work :  
Days Nights Sat Sun
 
 

WORK RECORD
Begin with most recent job, cover all periods of time, including when unemployed.
 
Employer* :
Employed From : To :
Address* : Phone* :
Type of Business : Job Title :
Immediate Supervisor :
Pay Rate ($) From : To :
Job Duties* :
What did/do you like about this job ?
Reasons for Leaving ?
May we contact ?
 
 
Employer :
Employed From : To :
Address : Phone :
Type of Business : Job Title :
Immediate Supervisor :
Pay Rate ($) From : To :
Job Duties :
What did/do you like about this job ?
Reasons for Leaving ?
May we contact ?
 
 
 
Employer :
Employed From : To :
Address : Phone :
Type of Business : Job Title :
Immediate Supervisor :
Pay Rate ($) From : To :
Job Duties :
What did/do you like about this job ?
Reasons for Leaving ?
May we contact ?
 

EDUCATION AND TRAINING
 
Circle Highest Grade Completed :
10 12 Diploma Graduate
 
High School Attended :
 
Extra Curricular Activities/Work Experience in School :
College(s) Attended :
Extra Curricular Activities/Work Experience in College :
List Additional Education, Special Skills or Training
On the reverse side of this application, please explain why you want to work for Home Caregivers.
 
Are you fluent in other languages? If so, which languages:
Have you ever been fired from a position or asked to resign? If yes, where?
Explain:
Have you ever worked for a home care agency before? If yes, where and when?

REFERENCES
Please list three references that we may contact, preferably people whom you have worked with. One reference may be a friend or relative.
 
Name* : Telephone* :
Relationship :
Employer Friend Acquaintance Supervisor Other
 
 
Name* : Telephone* :
Relationship :
Employer Friend Acquaintance Supervisor Other
 
 
Name : Telephone:
Relationship :
Employer Friend Acquaintance Supervisor Other
 

GENERAL INFORMATION
In event of an emergency, whom would you wish to notify?
Name* : Address* :
City* : State :
Zip : Telephone* :
 
Have you ever been convicted of a felony?
Yes No
 
If yes, please explain:
(A prior conviction does not necessarily disqualify an applicant from employment, but failure to disclose a prior conviction WILL disqualify an applicant)
 
Other names under which your education or employment records may be verified:
 
Please read the following statement carefully, any questions regarding this application may be discussed during an interview. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts including age and/or employment information is cause for dismissal whenever discovered. Employees who are required to drive for the company is subject to our Driving Safety policies. Further, I understand and agree that my employment is for no definite period, and that, regardless of any company notices, memoranda or policies concerning my compensation while employed, I may be terminated at any time, for any reason or for no reason, without previous notice. I further understand that only the Administrator of the Company has authority to change the at-will nature of my employment through written agreement. I further acknowledge that by signing this employment application.