Employment Application

TOUCH OF LOVE SITTER SERVICE,LLC

3512 Godwin Court Suite B Mobile, Al 36693 || (251) 222-9751-Phone || (251) 243-0952-Fax
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.
Today's Date:

Month Day Year
Date
Position(s) Applied For:
Name

First Name Last Name
Address

Street Address

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.

Emergency Contact(s):

	Full Name	Phone Number
1
2

Valid Driver's License #:
State Issued
Expiration Date

Month Day Year
Date
Make and Model of Vehicle
Year of Vehicle

	Yes	No	Explain
Have you ever submitted an application here before?
Have you been employed here before?
Have you been given a copy of the Job description for the position for which you have applied to review?
Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Why are you interested in employment with us?
AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.
What date are you available to begin work?

Month Day Year
Date

Please complete all areas of availability:

	Mornings	Afternoon	Evenings	Overnights	Weekdays	Weekends
Available

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From:
To:

Please indicate all areas in which you are willing to work:

Baldwin County Mobile County

Please indicate the types of services which you are willing to provide:

	Willing
Companionship
Meal Preparation
Activities
Housekeeping (dust/vacuum)
Laundry/Ironing
Medication Reminders
Errands/Shopping / Transportation *(In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required).
Personal Care
Dementia /Alzheimer's Care

	Yes	No
Are you willing to provide service to a client with a pet?
Cats
Dogs
Are you willing to provide service to a client that smokes?
Are you willing to consent to a drug and criminal background check for employment consideration?

Job Related Skills
Describe any training or life skills you have that apply to caring for a senior:
Describe any work history you have that would apply to caring for a senior:
What do you like (or think you would like) most about working with older adults?
What do you like (or think you would like) least about working with older adults?
What personal rewards do you get from working with seniors?
Education

Please chose the highest grade completed:

	6th	7th	8th	9th	10th	11th	12th	13th	14th	15th	16th	16th+
Service Quality

Schools Attended

	School Name	City, State	Major/Subject	# Years Attended	Graduate Yes/No
High School
Vocational/Technical
College/University

Work History

Your Application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Most Recent Employer

	Answers
Company Name
City
State
Phone Number
Start Date
End Date
Job Title
Supervisor Name
Duties
Salary
Hourly Monthly Annual
Reason For Leaving
May We Contact this Employer

Second Most Recent Employer

	Answers
Company Name
City
State
Phone Number
Start Date
End Date
Job Title
Supervisor Name
Duties
Salary
Hourly Monthly Annual
Reason For Leaving
May We Contact this Employer

Most Recent Employer

	Answers
Company Name
City
State
Phone Number
Start Date
End Date
Job Title
Supervisor Name
Duties
Salary
Hourly Monthly Annual
Reason For Leaving
May We Contact this Employer

Security

*****Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.
As a condition of employment, all employees must be "Bondable and Insurable". Are you at least 19 years of age?

Yes No
List states and counties of residence for the past seven years:
Have you had any moving traffic violations?

Yes No
If yes, please describe:
Have you been charged/convicted of a felony and/or misdemeanor or served time?

Yes No

If yes, please describe:

	Incident	City/State	Charge
1
2

References

Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references.

(Do not include relatives)

	Full Name	Phone Number	Best Time of Day to Call	Relationship	Number of Years Known
1
2
3

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Touch of Love Sitter Service, LLC, and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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TOUCH OF LOVE SITTER SERVICE,LLC

AVAILABILITY

Job Related Skills

Education

Work History

Security

References