JOB APPLICATION

JOB APPLICATION
Seniors Paradise Homecare Agency 12373 Hagan Creek Dr, Jacksonville, Florida 32218 9047043901

Seniors Paradise Homecare Agency is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information Applicant Name: Address:
Applicant Name
City, State and Zip Code: Telephone Number: Email Address
Address

Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Email Address
example@example.com
Date of Application

MonthDayYear
Date
Employment Position Position(s) applying for:

How did you hear about this position? What days are you available for work? What hours or shift are you available for work? If needed, are you available to work overtime? On what date can you start working if you are hired? Do you have reliable transportation to and from work? Salary desired:
How did you hear about this position?
What days are you available for work?
What hours or shift are you available for work?
If needed, are you available to work overtime?
On what date can you start working if you are hired?

MonthDayYear
Date
Do you have reliable transportation to and from work?
Salary desired
Personal Information Have you ever applied to or worked for Seniors Paradise Homecare Agency before?
If yes, when?
If yes, state name & relationship
Do you have any friends, relatives, or acquaintances working for Seniors Paradise Homecare Agency If yes, state name & relationship:

Are you 18 years of age or older?
Are you a U.S. citizen or approved to work in the United States?
No
What document can you provide as proof of citizenship or legal status?
Will you consent to a mandatory controlled substance test?
Yes
Do you have any condition which would require job accommodations?
Yes
No
If yes, please describe accommodations required below.
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
Yes
No
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered

Job Skills/Qualifications Please list below the skills and qualifications you possess for the position for which you are applying:
Please list below the skills and qualifications you possess for the position for which you are applying
(Note: Seniors Paradise Homecare Agency complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions

Education and Training High School Name
Name
Location (City. State)
Year Graduated
Degree Earned
Name
Location (City. State)
Year Graduated
Degree Earned
Vocational School/Specialized Training Name
Name
Location (City. State)
Year Graduated
Degree Earned
Military
Are you a member of the Armed Services?
What branch of the military did you enlist? What was your military rank when discharged? How many years did you serve in the military?
What branch of the military did you enlist?
What was your military rank when discharged?
How many years did you serve in the military?
What military skills do you possess that would be an asset for this position?
Previous Employment Employer Name: Job Title:
Employer Name
Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving
Supervisor Name
Job Title
Address

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Dates Employed

MonthDayYear
Date
Reason for leaving
Employer Name
Job Title
Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving
Supervisor Name
Address

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Dates Employed

MonthDayYear
Date
Reason for leaving
Employer Name
Job Title
Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving
Employer Address
Supervisor Name
City, State and Zip Code
Dates Employed

MonthDayYear
Date
Reason for leaving
References Please provide 2 personal and professional reference(s) below:
Reference
The relationship between you and the Seniors Paradise Homecare Agency is referred to as "employment at will." This means that your employment can be terminated at any time for any reason,
with or without cause. with or without notice, by you or the Seniors Paradise Homecare Agency. No representative of Seniors Paradise Homecare Agency has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.
Applicant Signature

Clear
Dated

MonthDayYear
Date
SENIORS PARADISE HOMECARE AGENCY LLC
PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION
I, understand that as part of the employment process, Seniors Paradise Homecare Agency LLC needs to complete a background check on me regarding
understand that as part of the

employment process, Seniors Paradise Homecare Agency LLC needs to complete a background check on me regarding:

2. Sex and Violent Offenders Record

4. Education Verification 5. License Verification
7. Personal/Professional Reference Verification
8. Medical Suitability 9. Drugs/Alcohol 10. Child Abuse Clearance (if applicable) I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to Seniors Paradise Homecare Agency LLC or its authorized representative. I understand that this authorization is to be part of the written and signed employment application. I also understand that do not have to give authorization for a background check but if I don't give permission, my employment application will not be processed further. I understand that I have specific rights under the federal Fair Credit Reporting Act and may have additional rights under relevant State Law. I further authorize that a photocopy of this authorization may be considered as valid as the original. I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Seniors Paradise Homecare Agency LLC is contingent upon successful completion of a background check.
FULL NAME
Telephone #
Former Name(s) and Date(s) used

MonthDayYear
Date
Current Address
Date of Birth

MonthDayYear
Date
Social Security Number
Current Driver's license
State
List any other cities, states and dates of residency during the 10 years (Use back of sheet, if necessary)

To: Month/Year From: Month/Year
To
-5-8
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

JOB APPLICATION

SENIORS PARADISE HOMECARE AGENCY LLC

PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION