Employment Application

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Personal Information
Last Name
First Name
Middle InitialMiddle Initial
Street AddressStreet Address
Apartment #Apartment #
CityCity
StateState
Zip CodeZip Code
Date available to StartDate available to Start
date_range
PhoneCity
Position & Availability
Position Applying ForPosition Applying For
Years of Related ExperienceYears of Related Experience
Wage DesiredWage Desired
How Well Can You Speak English?
Are you Available for 24 Hour-Live In?
Languages You Can SpeakLanguages You Can Speak
How Many Hours Are You Willing to Work?How Many Hours Are You Willing to Work?
You May Be Required to Fill in For Other Caregivers When Needed. Will You Be Available for Short Notice/Fill-In?
Transportation
Do You Have a Valid License?
StateState
License #License #
Do You Have a Car?
MakeMake
ModelModel
Insurance ProviderPolicy #
Policy #Policy #
Are you Willing To Travel?
Distance Willing to TravelDistance Willing to Travel
Areas Willing To Service
Education
High SchoolHigh School
City / StateCity / State
CollegeCollege
City / StateCity / State
OtherOther
City / StateCity / State
Degree / CertificationDegree / Certification
Special Skills or TrainingSpecial Skills or Training
Emergency Contact

Please provide us with two (2) Emergency contacts that we would be able to contact in the event of an emergency.

Last NameLast Name
First NameFirst Name
Full AddressFull Address
Phone NumberPhone Number
RelationRelation
Last NameLast Name
First NameFirst Name
Full AddressFull Address
Phone NumberPhone Number
RelationRelation
Criminal History
Have you ever been arrested for Felony or Misdemeanor?
If Yes, Please explainIf Yes, Please explain
0 /
Have you Ever Been Convicted of a Felony or Misdemeanor?
If Yes, Please explainIf Yes, Please explain
0 /
Do you have any pending charges, felony or misdemeanor?
If Yes, Please explainIf Yes, Please explain
0 /
Employment History
Most Recent EmployerMost Recent Employer
Reason for LeavingReason for Leaving
AddressAddress
Phone NumberAddress
SupervisorSupervisor
DutiesDuties
0 /
May We Contact Them?
Start DateStart Date
End DateEnd Date
CompanyCompany
Reason for LeavingReason for Leaving
AddressAddress
Phone NumberPhone Number
SupervisorSupervisor
DutiesDuties
0 /
May We Contact Them?
Start DateStart Date
End DateEnd Date
CompanyCompany
Reason for LeavingReason for Leaving
AddressAddress
Phone NumberPhone Number
SupervisorSupervisor
DutiesDuties
0 /
May We Contact Them?
Start DateStart Date
End DateEnd Date
References

Please provide us with at least three professional references

Last NameLast Name
First NameFirst Name
Phone NumberPhone Number
RelationshipRelationship
Last NameLast Name
First NameFirst Name
Phone NumberPhone Number
RelationshipRelationship
Last NameLast Name
First NameFirst Name
Phone NumberPhone Number
RelationshipRelationship
Experience
Discuss any training or experience you’ve had with the elderlyDiscuss any training or experience you’ve had with the elderly
0 /
What do you enjoy the most about working with the elderlyWhat do you enjoy the most about working with the elderly
0 /
Skills Check ListPLEASE MARK OFF ITEMS YOU HAVE EXPERIENCE WORKING WITH

APPLICATION MUST BE FILLED OUT IN ITS ENTIRETY TO BE CONSIDERED…
I certify-
• That the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
• I understand that this is not a legally binding contract and does not guarantee employment with From The Heart Home Care, LLC.
• That, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to From The Heart Home Care, LLC and I hereby release and discharge any of the above From The Heart Home Care, LLC from any liability of any kind or nature.
• That it is my responsibility to keep such information current and accurate by updating it as often as necessary.
• The agency shall make the form and comprehensive background check available for inspection by agent of the Department of Consumer Protection during reasonable times.
• I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test, if part of the Agency’s pre-employment policy.
• I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States

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