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 us, an independently owned and operated ANBHCS 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.

Have you ever submitted an application here before? Yes / No If yes, when?

Have you ever been employed here before? Yes / No If yes, when?

Have you have been given a copy of the job description for the position for which you have applied to review. Yes / No Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? Yes / No

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

Please complete all areas of availability:

Please indicate the days of the week as well as the earliest and latest times that you are available for work. Thursday MondayWednesday TuesdayFriday ShiftFrom:

Please indicate the types of services which you are willing to provide: Companionship Meal Preparation Laundry/Ironing Medication Reminders Activities (games/crafts) 'Inorder to be able to provide transportation or run errands, you will be required to have a valid driver's license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required

Errands/Shopping/Transportation* Personal Care

Are you willing to provide service to a client with a pet? Yes / No If yes, which ones:

Are you willing to provide service to a client that smokes? Yes / No

Please circle highest grade completed:

College: 13 14 15 16 16+ Major/Subject

College/University "For employment our minimum education requirement is either a GED or High School diploma

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Are you currently working for this employer? Yes / No If yes, may we contact? Yes / No

Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check. As a condition of employment all employees must be "Bondable"& "Insurable". Are you at least 19 years of age? Yes / No List states and counties of residence for the past seven years:

Have you had any moving traffic violations? Yes / No If yes, please describe:

Have you been charged/convicted of a felony and/or misdemeanor/or served time Yes / No If yes, please describe: IncidentCity/StateCharge 1)

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? Yes or No. REFERENCES (Do not include relatives) Please complete all six references. Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 6 references, you will be askedto provide additional references. Best Time of Day to Call Relationship ) ) ) 2)

 

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) 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. I understand that any false information, omissions or misrepresentations of facts 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 nsumer-reporting bureaus, to verify any of this 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. Irelease this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. 1 also understand that if hired. regardless of any oral presentations to the contrary, the employment relationship myself is terminable at-will,

so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read. understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.