Employment Application Form

Employment Application Form
Personal Information
Date of Application

MonthDayYear
Date
Name

First NameLast Name
Gender
Race
Social Security Number
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Please enter a valid phone number.
Telephone Number
Please enter a valid phone number.
Email
example@example.com
How did you hear about us?
Type of employment desired

Part timeFull time
Please specify days and hours
Position applied for
Part timeFull time
Current hourly pay rate ($)
Desired pay per hour ($)

Employment Background
1. Name of previous employer

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start pay per hour ($)
End pay per hour ($)
Job Title
Responsibilities
Start of employment

MonthDayYear
Date
End of employment

MonthDayYear
Date
Reason for leaving
Name of supervisor

First NameLast Name
Phone Number
Please enter a valid phone number.

2. Name of previous employer

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start pay per hour ($)
End pay per hour ($)
Job title
Responsibilities
Start of employment

MonthDayYear
Date
End of employment

MonthDayYear
Date
Reason for leaving
Name of supervisor

First NameLast Name
Phone Number
Please enter a valid phone number.

3. Name of previous employer

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start pay per hour ($)
End pay per hour ($)
Job title
Responsibilities
Start of employment

MonthDayYear
Date
End of employment

MonthDayYear
Date
Reason for leaving
Name of supervisor

First NameLast Name
Phone Number
Please enter a valid phone number.

References
List the name, relationship, number of years acquainted and phone number of 3 references. (No relatives please)
Reference 1

First NameLast Name
Relationship
Number of years acquainted
Phone Number
Please enter a valid phone number.
Reference 2

First NameLast Name
Relationship
Number of years acquainted
Phone Number
Please enter a valid phone number.
Reference 3

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Number of years acquainted

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**CERTIFICATION AND RELEASE:

I certify that I have read and understand the application note on page 2 of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. Iunderstand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

We are an equal opportunity employer, dedicated to a policy ofnon-discrimination in employment on any basis including race,color, age, sex, religion, disability, national origin, ancestry,veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws
Applicant's signature

Clear
Date

MonthDayYear
Date

Reference Checking Consent and Authorization Form
Disclosure
I ,First Name Last Name, have applied for employment with Truly Cares Home Care Service, LLC and have provided information about my previous employment. I authorize Truly Cares Home Care Service to conduct a reference check with my present and/or previous employer (s). I understand the that the reference information may include, but not be limited to, verbal and written inquires or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary, and employment history. My signature below authorizes my former or current employer and references to release information regarding my employment record with their organization and to provide any additional information that may be necessary to for my application for employment
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear

Should be Empty:

	Current	Expired
CNA Certification
CPR / First Aid
Driver's License
TB Screening

Employment Application Form

Personal Information

Employment Eligibility

FYI: A conviction will not be a determining factor in continuing the pre-screening process or potential employment opportunities

Education

Employment Background

References

List the name, relationship, number of years acquainted and phone number of 3 references. (No relatives please)

Reference Checking Consent and Authorization Form

Disclosure