Employment Application Form

Education Employment History/License/Certification
Name of School *
Year of Graduation

MonthDayYear
Date
Degree*
Company Name *
Start Date *

MonthDayYear
Date
End Date

MonthDayYear
Date
Job Description*
Supervisor Name*
Supervisor Phone #

Area CodePhone Number
YesNo
Company Name *
Start Date *

MonthDayYear
Date
End Date *

MonthDayYear
Date
Job Description*
Supervisor Name*
Supervisor Phone #*

Area CodePhone Number
YesNo
Training or Certifications:
Add your certification here if you have any (optional)

References
References Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

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.

NOTICE TO APPLICANT CONCERNING ERASED CRIMINAL RECORDS

Under Connecticut law (1) You need not disclose the existence of any arrest, criminal charge or conviction that has been erased; (2) records subject to erasure for these purposes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nulled, a criminal charge for which the person has been found not guilty, and a conviction for which a person received an absolute pardon; and (3) any person whose criminal records have been so erased shall be deemed never to have been arrested with respect to the erased records and may so swear under oath.

The agency shall conduct a comprehensive background check of all employees and prospective employees. The agency shall require the employee or prospective employee to complete and sign a form which contains questions as to whether the current or prospective employee has been convicted of a crime involving violence or dishonesty in a state court or federal court in any state, or was subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction.

CERTIFICATION STATEMENT:
"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 I 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."

Constant Care Home Care Agency is an equal opportunity employer committed to hiring a diverse workforce.
Signature*
Date of Signature*

MonthDayYear
Today's Date

AUTHORIZATION/DISCLOSURES
Authorization

I personally, completed this form honestly and accurately. By my signature below, I promise that I have personally completed this application. I declare under penalty of perjury that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment if discovered at a later date. I understand that any job offer is conditional based on the satisfactory review of my qualifications including any and all background or drug screening which may be required.

Authorization to obtain information

I voluntarily and knowingly authorize any present or past employer; supervisor; administrator; educational institution; law enforcement agency; state, local, or federal agency; credit bureau; collection agency; private business; military branch; the national personnel records center; personal reference; and/or other persons; to give records or information they may have concerning my criminal history, motor vehicle report, educational history, licensing, employment (including character, earnings history and reasons for termination) or any other information requested by the company requested to determine my eligibility for employment. CT state agencies would also be used to verify your employment eligibility

Constant Care Home Care Agency 1164 Burnside Ave, East Hartford CT 06108 Phone: 860-997-6929Info@constantcareathome.org https://constantcareathome.org

Release

I voluntarily waive all recourse and release any company, individual or organization from liability for complying with any request from the company or agents of the company (including any consumer reporting agency) to obtain any information from any source whatsoever relating to my application for employment. I further release the company or any individual within the company regarding the use any information received which may have bearing on my application for employment.

Notification and compliance with rules

I agree to immediately notify the company if I should be convicted of a crime while my job application is pending, or during my employment if hired. If I become employed, in consideration of my employment, I agree to comply with the rules, regulations, policies and procedures of the company. I certify that all of the information provided by me on this Application is true and accurate.

Continuous Education and In -service

I agree to complete the following trainings (HIPAA, Safety in Community, Pre-Cautions when traveling, Electrical Safety etc) prior to my start date as well as any continuous education in the form of In-services or online studying to enhance my performance at my job.

By signing below, you agree to the terms of employment above.
Signature*
Date of Signature*

MonthDayYear
Date
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