APPLICATION FOR EMPLOYMENT OR CONTRACT

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Last Name*

First*

Initial*

Social Security #*

Other Name(s) Used

Home Telephone # ()

Address*

Cell or Message #*

Position Applied For*

Referred By

Salary Desired*

Have you ever interviewed with the Company or its affiliates before?*

YesNo

If yes, list date(s)

Date

If yes,list job titles & locations

Have you ever been employed by the Company or its affiliates before?*

YesNo

If yes, list date(s)

Date

If yes, list dates job titles & locations

Do you have any relatives employed by the Company or its affiliates?*

YesNo

If yes, list date(s)

Date

If yes, list job titles & locations

Are you at least 18 years old?*

YesNo

If under 18, do you have a work permit?

Please check Highest Grade Completed:

High School*

9101112

College, Trade or Business

1234

Graduate Studies

High School*

Major Studies

Degree, Diploma, License or Certificate

College/University

Address

Major Studies

Degree, Diploma, License or Certificate

Vocational, Business, Other

Address

Major Studies

Degree, Diploma, License or Certificate

List Any Professional Designations

In what language(s) other than English are you fluent? Write Speak Read Language:

Language

Please check

Speak SpeakReadWrite

Language

Please check

SpeakReadWrite

Language

Please check

SpeakReadWrite

For Clerical Applicants Only

Do you type?

NoYes

If yes, WPM

Computer Skills (Hardware/Software)

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List prior five (5) years of employment history, starting with the most recent position. All information must be completed. You may attach a resume, but not in place of completing the required information. Pierce-Foley, LLC (DBA- Always Best Care Home Health) will contact at least two previous employers to verify the position held, dates of employment and eligibility for rehire. Ask for an additional Employment History Sheet, if needed.

Employed From*

Employer Name*

Supervisor Name

Starting Salary

Employed Until*

Employer Address*

Supervisor Phone #*

Ending Salary

Job Title

Reason for Leaving

Duties and Responsiblities

Employed From

Employer Name

Supervisor Name

Starting Salary

Employed Until

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Employed from

Employer Name

Supervisor Name

Starting Salary

Employed Until

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Employed from

Employer Name

Supervisor Name

Starting Salary

Employed Until

Employer Address

Supervisor Phone

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

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Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?

YESNO

Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or seals by court? (A "yes" response does not automatically disqualify your application

YESNO

Do you plan to evacuate the area in the event of a disaster?

YESNO

If no, do you intend to continue providing service to Agency clients as long as you are able?

YESNO

Will you work for holidays?

YESNO

Are there any days of the week that you cannot work? If yes, please list those days:

YESNO

Check the shifts you can work

3PM-11PM7AM-3PM11PM-7AM

Can you work a 24-hour shift?

YESNO

The above information is true and correct. I understand that, in the event of my employment or contract by the Company, I shall be subject to dismissal if any of the information I have given in this application is false or misleading. or if I have failed to give any information herein requested. regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information

I understand that nothing in this application, the granting of an interview or my subsequent employment or contract with the Company. is intended to create an employment contract between myself and the Company. On the contrary I understand and agree that, if hired or contracted. my association will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing.

I hereby acknowledge that I have read and agree to the above statements.

Signature*

Date*

Date

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RESTORE HOME HEALTH AGENCY

APPLICATION for EMPLOYMENT or

CONTRACT

PERSONAL

EDUCATION

EMPLOYMENT HISTORY

GENERAL

CERTIFICATION & AUTHORIZATION