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Our Services
Advanced Clinical Care
Personal Care Assistance
Memory & Wellness Care
Transitional Care
24 Hour Care
Companionship
Respite Care
Certified Home Health Aide (CHHA) – Coming Soon
Careers
About
Service Areas
Contact Us
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All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
Personal Information
Last Name
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First Name
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Middle Name
Date
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Street Address
Home Phone
City, State, Zip Code
Business Phone
Emergency contact (person not living with you)
Have you ever applied for employment with this Agency?
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How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
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How did you learn of our organization?
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Are you willing to work
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Position applying for
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Education
College
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Course of Study
Degree/Dip
Vo-Tech or Trade
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Course of Study
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High School
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Location of School
Course of Study
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Other
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Location of School
Course of Study
Degree/Dip
Employment
List the last five years employment history, starting with the most recent employer.
1. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
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To
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Starting Pay
Job Title and describe your work
Reason for leaving
2. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
3. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
4. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
5. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
Was your last name different from your present name during the above listed jobs?
Yes
No
If yes, what was your name?
Are you currently employed?
Yes
No
Do you have reliable transportation?
Yes
No
Professional References
Persons who can furnish information about job performance
1. Name
Telephone
Address
2. Name
Telephone
Address
3. Name
Telephone
Address
General
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
Yes
No
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?
Yes
No
If you answered No, which job requirement can you not meet?
(2) Applicant Reference Check
To Whom It May Concern:
The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
To be filled out by applicant:
Applicant Name
Date of Application:
MM slash DD slash YYYY
Previous Employer
Contact Person
Address
Phone
I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicant’s Signature
Date
MM slash DD slash YYYY
To be completed by previous employer:
Date of employment:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Would you rehire this individual?
Yes
No
Responsibilities
Reason for Leaving
Rate of Pay: (weekly/biweekly/salary)
Additional comments (training/skills)
Reference check performed by
Employee Emergency Contact Information
Employee Name
Current Address
Home Phone
Cell Phone
*In case of emergency, please contact:
Name
Phone
Relationship
Address
*Please notify this Agency immediately if any of the emergency contact information changes.
Signature
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Date
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