A Mother’s Promise Home Health Aide Employment Application

A Mother’s Promise Home Health Aide Employment Application
463-201-9249

Amotherspromisehcs@gmail.com
Date*

MonthDayYear
Date
Position Summary: Home Health Aides help patients in a variety of ways, which may include taking their vital signs or giving them medicine under a nurse’s direction.

Hourly Wage: $12-$15 (wage is based on experience)

Direct Supervisor: DeAndra Dycus

Education Requirements: High school diploma/GED

Direct Deposit is expected as a condition of new hire employment.

As a condition of employment, all applicants for employment must be qualified to work in the United States without sponsorship by A Mother’s Promise Home Care Services. If you are not work-authorized and would require A Mother’s Promise Home Care Services to sponsor you for a work visa you will not be considered for employment.
Applicant’s First and Last Name*
Date of Birth*
Phone Number*
Address*

Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Email Address*
example@example.com
Emergency Contact Name & Number*
Availability (Check all that apply):
Monday*

MorningAfternoonEveningOvernightUnavailable
Tuesday*

MorningAfternoonEveningOvernightUnavailable
Wednesday*

MorningAfternoonEveningOvernightUnavailable
Thursday*

MorningAfternoonEveningOvernightUnavailable
Friday*

MorningAfternoonEveningOvernightUnavailable
Saturday*

MorningAfternoonEveningOvernightUnavailable
Sunday*

MorningAfternoonEveningOvernightUnavailable
When will you be able to start*
Work Experience
A resume may be emailed to amotherspromisehcs@gmail.com giving a more detailed description of work performance or a listing of additional jobs. If you submit a resume to supplement your work history, you must still answer the questions on this form about dates, titles, and reasons for leaving.
Employers Name #1*
Job Title*
From: To:*
Address*
Phone Number*
Supervisor/Title*
May we reach out to your present/past employer*
Reason for leaving*
Duties*
Employers Name #2*
Job Title*
From: To:*
Address*
Phone Number*
Supervisor/Title*
May we reach out to your present/past employer*
Reason for leaving*
Duties*
Education
Do you have a high school diploma or GED (preferred but not required)?*

Name, location, and date completed:

	HS/College/University Name & Location	Major Field of Study	Dates Attended	Degree & Date	Credits Completed
1
2
3

Trainings/Skills/Certifications
Describe any specialized training, skills, or certifications
References

List three references who are not related to you and who have knowledge of your qualifications for the position for which you are applying. Do not repeat the names of supervisors listed under work experience.

	Full Name	Relationship	Number	Email Address
1
2
3

Within the last five years have you been fired for any reason? If yes, please provide details.*
UNDER THE IMMIGRATION CONTROL ACT OF 1986, AN EMPLOYER IS REQUIRED TO HIRE ONLY U.S. CITIZENS AND LAWFULLY AUTHORIZED ALIEN WORKERS. APPLICANTS WHO ARE SELECTED FOR EMPLOYMENT WILL BE REQUIRED TO SHOW AND VERIFY AUTHORIZATION TO WORK IN THE UNITED STATES.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital status, the presence of a non-job-related medical condition or disability, or any other legally protected status.
I acknowledge that if I am hired, I will undergo a background check and understand that I will have to take a drug test. Please print your name in the field below.*
I give A Mother’s Promise Home Care Services permission to verify all references listed and to obtain verification from employers of employment dates, reasons for separation, results of performance evaluations, and any other information relevant to verification of performance. Please print your name in the field below.*
Have you been convicted of a felony in the last five years? If yes, please explain.*
Are you currently awaiting trial for a felony charge? If yes, please explain.*
I hereby acknowledge that I have read and understand this application. I also hereby affirm that this application contains no willful misrepresentations or falsifications and that the information contained herein is true and accurate to the best of my knowledge. I understand should the investigation at any time disclose any misrepresentation or falsification of information contained in this document, my application will be disapproved, and my name removed from any further consideration for employment. I also understand that should I be offered employment and accept a position with A Mother’s Promise Home Care Services, and it is subsequently discovered that the information provided herein is false; I may be terminated from employment immediately.
Signature*
Date Signed*

MonthDayYear
Date
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A Mother’s Promise Home Health Aide Employment Application

Work Experience

Education

Trainings/Skills/Certifications

References