Application for Employment

Application for Employment

Please complete all sections of application then select "SUBMIT" in the Release and consent section to submit application to a member of Home to Stay.
Position Applying For*
County or Counties You Are Able To Work In (Live-Ins May Check All)*

BurlingtonCamdenGloucesterSalem
Full Name:*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*
Social Security #*
Enter your social security number
Were you referred to Home To Stay?
Please enter the name of who referred you so we can thank them:

Emergency Contact Information
Emergency Contact:*

First NameLast Name
Relation to You*
Phone Number*

Area CodePhone Number
Email Address
example@example.com

Education & Experience
Upload a copy of your resume

Browse Files
Upload resume Cancelof
Highest Level of Education Completed*

High School Diploma/GEDAssociate's DegreeBachelor's DegreeOther
Describe any specialized training, skills and activities that would qualify you for this position:*
How many years of experience do you have in healthcare?*
Employment History

You must supply a minimum of 12 months of work history. Include all employers, both agency and private pay, if applicable.
Most Recent Employer Name:*
Company Name
Most Recent Employer Location:*
City, State
Previous Job Title:*
Dates of Employment:*

MonthDayYear
Start Date
MonthDayYear
End Date: (Leave blank if present)
Previous Duties Preformed*
Name of Supervisor

First NameLast Name
Supervisor Phone Number

Area CodePhone Number
Employer Name:*
Previous Employer Location:*
Previous Job Title:*
Previous Dates of Employment:*

MonthDayYear
Start Date
MonthDayYear
End Date:
Previous Duties Preformed:*
Name of Supervisor

First NameLast Name
Supervisor Phone Number

Area CodePhone Number

Employment References
Home To Stay requires each applicant to provide a minimum of two (2) personal references and two (2) professional references.
Personal Reference #1*
Okay to contact Personal Reference #1?

YesNo
Personal Reference #2*
Permission to contact Personal Reference #2?

YesNo
Professional Reference #1*
Permission to contact Professional Reference #1?

YesNo
Professional Reference #2*
Personal Reference Name*
Permission to contact Professional Reference #2?

YesNo
Personal Reference Phone Number*

Area CodePhone Number
Email*
example@example.com
Relationship*
Professional Reference Name*
Professional Reference Phone Number*

Area CodePhone Number
Email*
example@example.com
Relationship*

General Questions
Do you carry malpractice insurance?

YesNo
Have you received the Covid-19 Vaccine?*
Are you vaccinated for COVID-19?
Do you have a valid Driver's License?*

YesNo
Do you have experience working with clients living with dementia?*

YesNo
Do you have a valid CHHA License in New Jersey?*

YesNoNot Applicable
Enter your NJ CHHA License Number:
NJ CHHA Expiration Date
Expiration Date of CHHA License

MonthDayYear
Date

Background Screening Disclosure and Authorization
Disclosure(s)
My signature below authorizes the procurement of a consumer report and/or investigative consumer report upon H2S's request in conjunction with my application for employment or during the course of my employment. The results of the reports may be shared among H2S and the reporting agency, when necessary, and release of consumer reports that I am authorizing will be considered for employment purposes.
Authorization
My signature below authorizes the procurement of a consumer report and/or investigative consumer report upon H2S's request in conjunction with my application for employment or during the course of my employment. The results of the reports may be shared among H2S and the reporting agency, when necessary, and release of consumer reports that I am authorizing will be considered for employment purposes.
I have read the BACKGROUND SCREENING DISCLOSURE and AUTHORIZATION; and I UNDERSTAND IT, and I AGREE TO THESE TERMS.
Full Name:*

First NameLast Name
Today's Date:*

MonthDayYear
Date
Zip Code:*
Signature*

Clear
*This information is required for accurate record verification and will not be used for any other purpose, Federal law prohibits discrimination in employment on the basis of age, race, religion, sex or national origin.

Release and Consent
Release and Consent for Drug Testing

For employment-related purposes, I understand that Home to Stay, LLC (H2S) may ask me to submit to testing for drugs, alcohol, controlled substances, and/or inhalents unless prohibited by law. This will include mandatory pre-employment drug testing prior to employment with H2S, testing after an accident occurs on the job, or testing based on reasonable cause to believe I am under the influence of controlled substances during work hours or representing the company. I further understand periodic or random basis testing may occur at anytime during my employment with H2S.

If H2S asks me to do so, I consent to drug testing. I authorize H2S or any hospital, clinic, labratory, or medical review officer/organization to conduct the drug testing and to analyze and furnish results that may be shared with eachother. The result of the testing shall be conclusive.

If the test results are considered unfavorable by H2S, I agree that H2S may deny me employment, may remove me from an assignment, or may terminate my employment.

I release H2S and any organization conducting test(s) from any liability for the above action.

I agree to notify H2S, with five days, of any criminal conviction for a drug-related offense occuring during my employment.
I have read this Release and Consent for Drug Testing; I understand it and I agree to its terms.
Full Name

First NameLast Name
Todays Date

MonthDayYear
Date
Signature*

Clear
Should be Empty: