Good Hands Job Application

APLLICATION FOR EMPLOYMENT

Notice to Applicants: Good HandsCommunity Care LLC. is an equal opportunity employer. We do not discriminate on the basis of race,color, religion, creed, sex, disability or medical condition, national origin,veteran status, and all other categories protected by federal, state, and localanti-discrimination law in the recruitment, selection, training, compensation,and promotion of our employees.
Application Date*

MonthDayYear
Full Name*

First NameLast Name
Gender*

FemaleMalePrefer to not to identify
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Day Time Phone*

Area CodePhone Number
E-mail*
Referred By

First NameLast Name
List any friends or relatives that work for this company
When can you start?*

MonthDayYear
Are you willing to take a drug test? *

YesNo
Are you a Certified Nursing Assistant (CNA)?

YesNo
Are you Relias Trained?

YesNo
Do you have a valid driver's license?*

YESNO
What is your desired pay?*
What is your desired pay per hour? *
How Many Hours Do You Want to Work Per Week?*

0-1010-2020-3030-4040+
Select all days you are available to work*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What times are best for you?*

8am-1pm1pm-5pm5pm-10pm10pm-7am
Please share any additional credentials / skills
WORK HISTORY / EXPERIENCE

Please list your 3 most current work history/experience
Employer's Name (Most current)*
Position Held*
Duties*
Telephone*

Area CodePhone Number
Start Date*

MonthDayYear
End Date*

MonthDayYear
(2) Employer's Name
Position Held
Duties
Telephone

Area CodePhone Number
Start Date

MonthDayYear
End Date

MonthDayYear
PERSONAL REFERENCE
Personal Reference (1) Name*
Reference (1) Telephone*

Area CodePhone Number
(Office Staff Only) Reference Checked?

YesNo
Personal Reference (2) Name*
Reference (2) Telephone*

Area CodePhone Number
(Office Staff Only) Reference Checked?

YesNo
Business Reference (3) Name
Reference (3) Telephone

Area CodePhone Number
(Office Staff Only) Reference Checked?

YesNo
BACKGROUND RELEASE

I authorize Good Hands Home Care to perform a background review for my employment consideration.
My background check authorization*

ApproveDecline
Have you ever been convicted of any criminaloffense (felony or misdemeanor) including drunk driving, drug related offenseor elderly abuse? If yes, explain in full giving dates and offense. (Note:Any applicant who falsifies any information on this application is subject totermination. All information provided isheld confidential) *
APPLICANT'S STATEMENT .

I certify that the information, answers and statements made by me in this application are correct to the best of my knowledge andunderstand that any falsification of this information is grounds for dismissal. I authorize the references listed above to give you any and allinformation concerning my previous employment and any pertinent information they may have, personal or otherwise, and release allparties from all liability and claims for any damage that may result from furnishing same to you. In consideration of my employment, Iagree to conform to the rules and regulations of the Good Hands Community Care LLC. I understand that my employment andcompensation can be terminated with or without cause, and without notice, at any time at the option of either Good Hands Community CareLLC. or myself. I understand that as part of the processing procedure for my employment application, an investigative background reportmay be requested. Upon written request within a reasonable period of time, a complete and accurate disclosure concerning the nature andscope of the investigation may be furnished to me.I agree to take a drug test at any time, at the discretion of the company. I further agree that should the circumstance arise, I will submit topolygraph test in accordance with state and federal laws. I understand full the document I am signing. I understand that this application will remain active for a period of 90 days unless I review it personally and in writing, except in the event I am hired. It will remain activeuntil my separation.
Type Signature*
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