INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment
process, please notify the person who gave you this form and every reasonable effort will be made to
meet your needs in a reasonable amount of time
• Please read "Applicant Note" below.
• Complete all pages of this application.
• Print clearly. Incomplete or illegible applications may not be accepted.
• If more space is needed to complete any question, use comments section on the back.
• Application will be valid for 60 days.
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for
employment with our Home Care Agency. This is not an employment contract. Please answer all
appropriate questions completely and accurately. False or misleading statements during the interview
and on this form are grounds for terminating the application process or, if discovered after employment
begins, terminating employment. All qualified applicants will receive consideration and will be treated
throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or
any other protected class status under applicable law. Additional testing for the presence of illegal drugs
in your body may be required prior to employment.