Application for EmploymentHelping Hands At Home LLC

This agency is an equal opportunity employer. All qualified applicants will receive consideration for employment, without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disability. If you need help completing this application form, or any phase of the employment process, please notify the supervisor and every effort will be made to accommodate your needs in a reasonable amount of time. Additional testing of job-related skills may be required prior to employment. All facts, records, and information obtained will be held in the strictest confidence.

Helping Hands At Home Application For Employment Page 2 Employment History: Please list your 3 most recent employers. Phone Number Location Employer

Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied? A description of the activities involved in such a job is attached.YesNo Iauthorize investigation and screening of all references, and statements contained in the application for employment as may be necessary in arriving at an employment decision.YesNo I understand that I must undergo a drug screening, and do hereby give my consent to a drug screening prior to employment and at any time during my employment with or without notice from my employer. No Yes I understand that if I am offered employment, I will be working for Helping Hands At Home LLC, at its clients' No Yes premises. Iunderstand that Helping Hands At Home LLC may terminate my employment at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination. No Yes

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that, in the event of employment, false or misleading information given in my application or interview my result in discharge. No Yes Please attach any other experience and/or skills that may be relevant to the position in which you are applying, that were not listed on this application.