JOB APPLICATION

EDUCATION

Tell us a little about your education background. Thanks
High School *
Name of the high school you attended
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
From *

Month Day Year
Start Date
To *

Month Day Year
End Date
Did you graduate? *

Yes No
If you answered no to the last question, did you complete you GED or a Certificate equivalent to a GED or High School Diploma?

Yes No Currently attending
Name of College
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
To

Month Day Year
Start Date
From

Month Day Year
End Date
Did you graduate ?

Yes No Currently attending
Any other types of education you would like to share with us?
If yes, please explain

REFERENCES

Please list TWO(2) professional references, ONE(1) family or friend. Thanks
1. Name (professional) *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
Co-worker, manager, supervisor etc.
Company *
Where did you guys work together?
How many years have you known this person? *
May we contact this reference ? *

Yes No
2. Name (Professional) *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
Co-worker, manager, supervisor etc
Company *
Where did you guy work together?
Home many years have you known this person? *
May we contact this reference ? *

Yes No
3. Name (family/friend) *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
How many years have you known this person? *
May we contact this reference ? *

Yes No

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature *

Clear
Date *

Month Day Year
Date

WORK AVAILABILITY

As a future employee, we value and respect your time. Full time, part time, or per diem please let No Place Like Home LLC know what works best for you.
What amount of hour are you looking for *

30-40 hours per week 20-30 hours per week 10-20 hours per week under 10 hours per week

What days and times are you available to work? *

7am-3pm

3pm-11pm

11pm-7am

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

If you could be one animal from the list below, what would it be?

Please pick only one. Thanks
*

Dog Dolphin Monkey Moose Giraffe Goat Elephant Elk Eagle

COVID-19 SCREENING

You must complete this form before entering No Place Like Home LLC buildings. Thanks
Symptom History

Have you experenced any of the following symptons in the last 14 days?
- Fever or chills
- Cough
- Difficulty breathing
- fatigue
- Muscle aches
- Headache
- Sore throat
- Congestion
- Diarrhea
- Nausea or vomitting
If you answered YES to any of the above symptoms, please click YES. If you answered NO to all of the above symptoms, please click NO *

Yes No
Contact History
In the last 14 days have you had close contact with anyone who has been diagnosed with COVID-19 ? *

Yes No
In the last 14 days have you had close contact with anyone who has travelled to any other states or any other countries ? *

Yes No
Travel History
In the last 14 days have you travelled to any other states or any other countries ? *

Yes No
If you answered "YES" to the above question, please list all states and countries you have visited in the last 14 days
No Place Like Home LLC will review your form and contact you if needed. Our goal is to keep you, NPLH staff, and clients safe. Please make sure to wear a mask when entering all NPLH's buildings and client's homes.

NPLH expects all potential and current employee’s to self-screen every day and report any of the above symptom directly to NPLH management before entering NPLH's buildings and client’s home.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

No Place Like Home LLC