EMPLOYMENT APPLICATION for HOME CARE WORKER

At Home By Choice Home Care LLC

EMPLOYMENT APPLICATION for HOME CARE WORKER
Full Name*

First NameMiddle NameLast Name
Source
Date Of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Social Security #
GENDER
What language do you speak?
Emergency Contact # Name & Phone Number of Person to contact in the event of an emergency:

LocalOut of Area
Education

Please use this section to provide information about your previous education including the qualifications/certificates your have gained.
FORMAL

DiplomaCertificateDegreeOther
Work Limitations

List any work limitations that you may have and briefly describe:
Hearing
Speech
Lifting
Health
Physical
Emotional
Other
Availability for Work
Please list below the hours and number of shifts per week that you are available to be scheduled. This form should be used to indicate ALL available hours and not just the IDEAL schedule. Please understand that weekly schedules are not guaranteed, nor is the total number of hours per week. Schedules are established based on the current service requirements of the client. Limited availability may result'in fewer hours and/or scheduled shifts per week.

	FROM	TO
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

Select all that Apply *

	No Limitation	First Shift	Second Shift	Third Shift	Overnight	No schedule
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Special Request or Explanation of Limited Availability:
What is the minimum number of hours you will work in one day?
What is the maximum number of hours you will work in one day?
How many hours per week are you looking to work?
Are you able to work in Lake and Porter county?
What is your current rate of pay at current employer?

Reference Information

Work Related

Please note that providing employment references is a mandatory requirement for this application. Kindly ensure that you include accurate and up-to-date contact information for professional references who can speak to your work experience and qualifications.
Employment details (Required)*

CompanySupervisorPhone numberEmailJob title
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for leaving (Required)*
Employment details (Required)*

CompanySupervisorPhone numberEmailJob title
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for leaving (Required)*
Employment details (Required)*

CompanySupervisorPhone numberEmailJob title
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for leaving (Required)*
Refrences

Please use this section to provide a list of three professional references.

Please note that providing employment references is a mandatory requirement for this application. Kindly ensure that you include accurate and up-to-date contact information for professional references who can speak to your work experience and qualifications.
Referee 1 (Required/ preferred Past Supervisor)*

Full NameRelationshipPhone number Company
Address*
Referee 2 (Required/ preferred Past Supervisor)*

Full NameRelationshipPhone number Company
Address*
Referee 3 (Required/ preferred Past Supervisor)*

Full NameRelationshipPhone number Company
Address*
We have a background check that we perform to everybody? Is there anything that may come up ? *
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to At Home By Choice Home Care LLC and I hereby release and discharge any of the above and At Home By Choice Home Care LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I also understand that employment, for certain positions, may be conditional upon successful completion of drug testing and a criminal background check.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.
Signature

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At Home By Choice Home Care LLC