Pioneer Homecare Caregiver Employment Application Form

Employment Application Form

2 S Pointe Drive Suite 125 Lake Forest CA 92630 | 949-215-1423 | recruitment@pioneerhomecare.com www.pioneerhomecare.com
Employment Application Pioneer Homecare (the “Company”) Inc is an equal opportunity employer and makes employment decisions on the basis of merit. The Company prohibits unlawful discrimination against employees or applicants based on race (including traits historically associated with race, such as hair texture and protective hairstyles), religion, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, military status, veteran status, uniformed service member status, sexual orientation, transgender identity, citizenship status, pregnancy, or any other consideration made unlawful by federal, state, or local laws. The Company also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics, or is associated with a person who has or is perceived as having any of those characteristics. Applicants requiring accommodations to the application and/or interview process should contact Pioneer's Human Resource Representative.

Each question should be answered completely and accurately. No action will be taken on this application until all questions have been answered and the application has been signed and dated.

Fields with a red asterisk mark (*) are required to be answered. However, if a required field is not applicable to you, you may indicate "N/A" in order to proceed.
A. BASIC INFORMATION
1. Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
2. Address*

Street Address

Apartment # or Unit #

CityState

Zip Code
3. Cellphone Number*
Alternate Phone Number
4. E-mail*
example@example.com
Home Care Aide # (if applicable)
5. Gender*
6. I have a * . It is Number*
6. SSN / ITIN*
7. Do you drive?*

YESNO
If yes, do you have a valid driver license

YESNO
8. Are you fluent in a foreign language besides English?*

YESNO
If yes, what language(s)?
9. Are you currently employed?*

YESNO
10. Are you available to work?*

Full timePart time
11. How soon can you start working?*

MonthDayYear
12. Have you applied here before?*

YESNO
13. Have you been convicted of a felony/misdemeanor (other than traffic violations)?*

YESNO
If yes, please enumerate and explain.
B. REQUIREMENTS SUMMARY
1. Which of the following requirements can you provide? Check all that apply. (Please note that all requirements need to be valid, unexpired and current.)*

Live scan resultTB Test result / Chest X-Ray clearanceState ID or Driver licenseFirst aid or CPR certificationCDC CoVid-19 Vaccination Card showing proof of 2-dose vaccine or 1-dose if J&J, and booster dose/sHCA registration printout
C. EMPLOYMENT HISTORY

Please list your three most recent employers, list the most recent first.
1. Employer
Employer's Name (most current)
Address & location of business
Phone number
Your title
Supervisor's name
First and Last Name
Start date

MonthDayYear
End date

MonthDayYear
Work performed:
Reason for leaving
Do you wish to add more to your Employment History?

YESNO

Additional Employment History
2. Employer
Employer's Name (second most recent)
Address & location of business
Phone number
Your title
Supervisor's name
First and Last Name
Start date

MonthDayYear
End date

MonthDayYear
Work performed:
Reason for leaving
3. Employer
Employer's Name (third most recent)
Address & location of business
Phone number
Your title
Supervisor's name
First and Last Name
Start date

MonthDayYear
End date

MonthDayYear
Work performed:
Reason for leaving

END
Have you ever been asked to resign from any job?*

YESNO
If yes, please explain
Please explain any gaps in your employment history, if there's any.
D. EDUCATION
1. Highest level of education completed:*

2. Please complete the appropriate sections

	School Name	Location	Degree or Certification	Yrs Completed
GED / High School
College/University
Graduate School
Trade school
Other

E. BUSINESS AND PROFESSIONAL REFERENCES

List 3 professional references of individuals who are not related to you by blood or affinity. Include only individuals who are familiar with your work abiities.

1. References

	Name and Title	Relationship	Phone Number	Email address
1
2
3

F. GENERAL INFORMATION
1. Have you ever used another name?*

YESNO
2. If yes, please explain and provide information for the name change, assumed name or nickname used to check your work and educational record.

3. What days and hours are you available to work? (Please specify the time on the field. Example: 7am-3pm)

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
AM
PM
NOC

4. If hired, can you present evidence of your identity and legal right to work in this country?

YESNO
5. Are you able to perform the essential job functions of the job for which you are applying for, with or without reasonable accommodation?*

YESNO
6. How did you hear about Pioneer Homecare?*

Referred by a friend or familyReferred by a Pioneer representativeSocial Media (Instagram, Facebook, Google, Website, etc)Print ad (Brochure, pamphlet, directory, etc)Other
6.a If referred by a friend, family or Pioneer representative, please provide the name and phone number
ex: Jane Smith 949-111-1111
AUTHORIZATION I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed. I authorize Pioneer Homecare Inc to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to Pioneer Homecare Inc. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks). I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself, the employer or Pioneer Homecare Inc. at any time, with or without cause or notice, for any reason or no reason.
By entering your full name and signing below, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree
You must agree to accept the terms of the document in order to submit an application.
Type signature (Full Name)*
Signature*

Clear
Date*

MonthDayYear
Date
G. UPLOAD YOUR DOCUMENTS

You may upload multiple files at once but please upload ONE requirement/ID per file. Only clear copies of the requirements will be honored.
If available, please upload clear copies of the requirements and ID's mentioned above.

Req's: Live scan result, TB Test result / Chest X-Ray clearance, State ID or Driver license, First aid or CPR certification, CDC CoVid vaccine card, HCA registration printout
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Please upload a clear headshot picture of yourself. This picture will be used for your profile on our system and also your Pioneer ID once employed.

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Employment Application Form

Caregiving Skills, Knowledge and Experience