APPLICIATION FOR EMPLOYMENT
Applications for employment are considered without regard to race, color, sex, religion, age, national origin, marital status, or the presence of a non-job related medical condition or disability in compliance with all Federal and State equal opportunity laws.
AVAILABILITY
Date Available
Total Hrs/Week available
Laid Off/Subject to recall?
Position Status
(Please Check All That Apply)
Full Time
Part Time
Temporary
Per-Diem
On Call
Salary Desired
PERSONAL INFORMATION
Name
(Last, First, Middle)
Social Security
Present Address
(Street, City, State, Zip)
Telephone
Person To Contact In An Emergency
(Name, Telephone)
US Citizen
If No, Type of Visa
Alien Reg. #
Date Of Birth If Under 18
Have You Ever Been Convicted Of A Felony?
If Yes, Please Explain
Have You Been Employed Here Before?
If Yes, When?
Have you ever filled an applications here before?
(Yes, No, If Yes-When?)
How Did You Hear About Us?
(Referral, Newspaper, Etc)
Can you travel if job requires?
Driver's License
(Number, Expiration Date)
Military Information
EDUCATIONAL INFORMATION
High School
(Name, Address, # of Years Completed, Degree)
College
(Name, Address, # of Years Completed, Degree)
Other
(Name, Address, # of Years Completed, Degree)
PERSONAL REFERENCES
1. Reference
(Name, Business or Home Address, Telephone #, Occupation, Years Known)
2. Reference
(Name, Business or Home Address, Telephone #, Occupation, Years Known)
3. Reference
(Name, Business or Home Address, Telephone #, Occupation, Years Known)
EMPLOYMENT
(List Present or most Recent employer first. Volunteer work may be included)
1. Employer
(Employer Name, Address & Tel. #)
Date Employed
Position/Salary
Describe Your Duties
Supervisor's Name & Title
Reason For Leaving
May We Contact Employer?
2. Employer
(Employer Name, Address & Tel. #)
Date Employed
Position/Salary
Describe Your Duties
Supervisor's Name & Title
Reason For Leaving
May We Contact Employer?
3. Employer
(Employer Name, Address & Tel. #)
Date Employed
Position/Salary
Describe Your Duties
Supervisor's Name & Title
Reason For Leaving
May We Contact Employer?
Additional Skills Or Qualifications
Do you speak, read, or write a foreign language?
MEDICAL INFORMATION
Date Of Last Physical Exam/Results
Date Of Last TB Test/Results
Would lifting patients be a problem for you?
Problems Meeting Attendance Requirements?
(Yes, No, If Yes-Explain)
CERTIFICATION / LICENSE
Professional
Reg/License
(State, Reg/License #, Exp. Date)
HCA Certificate
(Yes, No, If Yes-Date)
Homemaker or PCA Training Certificate
(Yes, No, If Yes-Date)
EMPLOYMENT AGREEMENT
Please indicate your agreement with each of the following paragraphs by checking the corresponding box.
1
I understand that if I fail to report to an assignment or client and I neglect to give proper notification, I may be terminated.
2
Upon termination, I authorize the release of reference information regarding my work. I further agree to give proper notice of termination in order to be eligible for Earned Time accrued.
3
It is my understanding that a CORI ( Criminal Offender Record Information) check will be requested for all potential qualified in-home care providers and performed by the Criminal History System Board as the final step in our screening process prior to employment.
4
I certify that the information on this application is true, complete, and correct. I authorize the Great to be Home Care, Inc. to investigate my past employment, education, (without important omissions of any kind), activities, character, and qualifications and I release from liability all persons, companies, and corporations supplying such information. I certify that all statements and answers to questions regarding my health are true and were made without reservation. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial or employment discharge.
5
It is my understanding that this employment application, or grant of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, with or without just cause, at any time by my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this agency.
Information
Indicate below if any of your references and/or registrations are under a different name.
Signature/Date
(Please Type in Full Name)