UrbanCare Employment Application

EMPLOYMENT APPLICATION

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. 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.
PERSONAL INFORMATION
Today's Date*

MonthDayYear
Date
Position(s) Applied for*
Full Name*

First NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship*
Valid Driver's License / State ID#*

Cancelof
If Using a vehicle during work, Upload Car Insurance Info

Cancelof
Have you ever Submitted an application here before?*
if YES, when

MonthDayYear
Date
Have you ever been employed here before?*
if Yes, When

MonthDayYear
Date
How did you hear about our Home Care Agency?*
Have you been given a copy of the job description for the position you applied for?*
Are you able to perform the essential functions of the job for which you are applying for with or without a reasonable accommodation?*
Why are you interested in employment with us?*
YOUR AVAILABILITY
Due to the nature of the business, no guarantee can be made as to the schedule or amount of hours worked. What date are you available to begin work?*

MonthDayYear
Date
Please complete all areas of availability*

MorningsAfternoonEveningsOvernightsWeekdaysWeekends
Please complete the days of the week you are available*

SundayMondayTuesdayWednesdayThursdayFridaySaturday
If you have specific times you are available or unavailable please note the day of the week and the time frame you are available from start to finish for each day.
PREFERENCES:
Please indicate all areas of the city and surrounding areas you are willing to work*

North PhiladelphiaNortheast PhiladelphiaSouth PhiladelphiaWest PhiladelphiaBucks CountyMontgomery CountyChester CountyDelaware CountyOther
Please indicate the types of services you are willing to provide*

CompanionshipMeal PreparationActivities (games/crafts)Housekeeping (Dust/Vacuum)Laundry/IroningMedication RemindersWound CareErrands/Shopping/TransportationPersonal CareDementia/Alzheimer's CareLawn Care / GardeningOther
*In order to be able to run errands in an automobile, 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.
Are you willing to provide service to a client with a pet?*
If yes, which ones

CatsDogsOther
Are you willing to provide service to a client that smokes?
JOB RELATED SKILLS
Describe any training or life skills you have that apply to caring adults.*
Describe any work history you have that would apply to caring for adults.*
What do you like (or think you would like) most about caring for people?*
What do you like (or think you would like) least about caring for adults?*
EDUCATION

For employment our minimum education requirement is either a GED or High School Diploma
Have you completed either a GED or possess a High School diploma?*
School Name*
School City, State*
Number of Years Attended*
Did you graduate?*
Have you attended Vocational/Technical School*
School Name
City, State
Major/Subject
Number of years Attended
Have you attended/graduated College/University*
School Name
City, State
Major/Subject
Number of Years Attended
WORK HISTORY:

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.
MOST RECENT EMPLOYER:
COMPANY NAME*
Are you currently working for this employer?*
If yes, may we contact*
Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date you started working for this Employer*

MonthDayYear
Date
Date you stopped Working for this Employer*

MonthDayYear
Date
Job Title*
Supervisors Name*

First NameLast Name
Duties Performed*
Salary per (hour, week,month)*
Reason for Leaving:*
Did you have a Second Most Recent Employer?
COMPANY NAME*
Are you currently working for this employer?*
If yes, may we contact*
Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date you Started working for this Employer*

MonthDayYear
Date
Date you Stopped working for this Employer *

MonthDayYear
Date
Job Title*
Supervisors Name*

First NameLast Name
Duties Performed*
Salary per (hour, week,month)*
Reason for Leaving:*
Did you have a Third Most Recent Employer?*
COMPANY NAME*
Are you currently working for this employer?*
If yes, may we contact*
Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date you started working for this Employer*

MonthDayYear
Date
Date you stopped working for this Employer*

MonthDayYear
Date
Job Title*
Supervisors Name*

First NameLast Name
Duties Performed*
Salary per (hour, week,month)*
Reason for Leaving:*
SECURITY

**** 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 18 Years of Age?*
List the States and counties of residence for the past 7 years:*
Have you had any moving traffic violations?*
if yes, Please describe:*
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?*
REFERENCES
References (Do not include relatives)

Please Complete 3 References. Your Application will not be considered unless all 3 references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional References.
Reference Name # 1*

First NameLast Name
Reference Phone *
Please enter a valid phone number.Format: (000) 000-0000.
Reference Relationship #1 (No Family Members Allowed)*
Reference Relationship *
Number of years known*
Reference Name # 2*

First NameLast Name
Reference Phone #2*
Please enter a valid phone number.Format: (000) 000-0000.
Reference Relationship #2 (No Family Members Allowed)*
Reference Relationship*
Number of years known*
Reference Name # 3*

First NameLast Name
Reference Phone #3*
Please enter a valid phone number.Format: (000) 000-0000.
Reference Relationship #3 (No Family Members allowed)*
Reference Relationship*
Number of years known*
APPLICANT NOTICE:

It is illegal in Philadelphia for employers to ask about your criminal background during the job application process. Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depends on the results of your background check). * Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration). * Arrests that did not lead to conviction cannot be used in any employment decisions. *If your background check reveals a conviction, the employer must consider: The type of offense and the time that has passed since it occurred. Its connection to the job you are applying for; and *Your job history, character references, and any evidence of rehabilitation. *Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people. *If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision. *You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.
APPLICANT 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 consumer-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. I release 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. | 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. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and 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.
Date & Time of Form Submission*

MonthDayYear
Date
Hour MinutesAM/PM Option
Applicant Signature*
Should be Empty:

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

YOUR AVAILABILITY

PREFERENCES:

JOB RELATED SKILLS

EDUCATION

WORK HISTORY:

MOST RECENT EMPLOYER:

SECURITY

REFERENCES

References (Do not include relatives)

APPLICANT NOTICE:

APPLICANT CERTIFICATION AND RELEASE: