01. Application for Employment

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Date available:

Date

SSN #*

Please enter 9 digit Social Security number.

Position applied for:

Enter position type: eg: "HHA" or select from below more options:

More options:

CNAPersonal Care AideCompanion/HomemakerOther

Has your license ever been suspended or revoked?*

YESNO

Explain the reason:

Describe Details

Appling for:

Time Availability: (check all times you are available for work; times noted are approximate)

	MON	TUE	WED	THU	FRI	SAT	SUN
8 AM TO 12 PM
12 PM TO 4 PM
4 PM TO 8 PM
8 PM TO 12 AM
12 AM TO 4 AM
4 AM TO 8 AM

Are you a citizen of the United States?*

YESNO

If no, are you authorized to work in the U.S.?*

YESNO

Have you ever worked for this company?*

YESNO

If so, when?

Describe Details

Have you ever been convicted of a felony or misdemeanor?*

YESNO

If yes, detail:

Describe Details

Languages Spoken:

High School

Address

From

To

Did you graduate?:*

YESNO

Degree

College

Address

From

To

Did you graduate?:

YESNO

Degree

Other

Address

From

To

Did you graduate?:

YESNO

Degree

Full Name*

Relationship

Company

Address

Phone Number*

Please enter a valid phone number.

Full Name*

Relationship

Company

Address

Phone Number*

Please enter a valid phone number.

Company

Phone Number

Please enter a valid phone number.

Address

Supervisor

Job Title

Responsibilities

Starting Salary

Ending Salary

From

Date

To

Date

Reason for Leaving

May we contact your previous supervisor for a reference?:

YESNO

Company

Phone Number

Please enter a valid phone number.

Address

Supervisor

Job Title

Responsibilities

Starting Salary

Ending Salary

From

Date

To

Date

Reason for Leaving

May we contact your previous supervisor for a reference?:

YESNO

Branch

From

Date

To

Date

Rank at Discharge

Type of Discharge

If other than honorable, explain

PLEASE READ THIS STATEMENT CAREFULLY BEFORE SIGNING.
I understand that in processing my application with Galaxy Home Care, a background check will be conducted. Information may include but is not limited to: employment history, education, criminal records, national sex offender check, child abuse clearance, motor vehicle records, personal references, and any data provided on this application or during the interview process.

I authorize the appropriate individuals, companies, institutions, or agencies to release information and I release them from any liability as a result of such inquiries or disclosures.

I have read, understand, and consent to these statements by my signature. I hereby certify that all the statements and answers set forth on the application form, my resume, and interview are true and complete to the best of my knowledge. If this application leads to employment, I understand that if any statements and/or answers are found false or the information has been omitted, such false statements or omissions may cause rejection of my application or termination of my employment.

If currently employed: My current employer may be contacted?*

YESNO

Address

Street Address

Street Address Line 2

CityState

Address

Street Address

Street Address Line 2

CityState

Address

Street Address

Street Address Line 2

CityState

Address

Street Address

Street Address Line 2

CityState

Other Name(s) Used and Date(s)

DL/GC/State ID Number*

Expiration Date*

Date

State Issued*

Street Address

Street Address Line 2

State

Date of Birth*

Date

File Upload/Add Resume

Signature*

Date

Application for Employment

Personal Information

Position Specific Information

Education

Professional Reference - 1

Professional Reference - 2

Previous Employment

Previous Employment

Military Services

Employment Application Disclosure and Authority to Release Information

Please list any additional addresses where you have lived, worked and attended schools during the past 7 yrs.