Caregiver Employment Application Form Revised

Caregiver Employment Application Form
NOTE: Applicants are subject to background checks
PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE
Personal Information
PLEASE COMPLETE ALL QUESTIONS, PAGES 1-4
Last
First
Middle
Date
Street
City
Sate
Zip
How long at this address?
Social Security No.
Phone: ( )

Country CodeArea CodePhone Number
Position applied for: Have you ever applied here before: Yes
Please list age (if under 18)

Position applied for: Have you ever applied here before: YesNo
Please indicate the days and times you are available to work

Anytime
Salary range desired
Hours of availability Start time to end time and days of the week
How many hours can you work weekly?
Employment desired

Are you available to work weekends?PART-TIME ONLYFULL- OR PART-TIMEAre you legally authorized to work in the US:?
When are you available to start work?
Where did you hear about us?
Email address
example@example.com
Have you ever been convicted of a crime?

NoYes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment)

Education

	NAME OF SCHOOL	(City, State)	NUMBER OF YEARS COMPLETED	Did you graduate
High School
College

In Case of Emergency, Please Contact:
Name
Relationship
Phone
PLEASE READ CAREFULLY
APPLICATION FORM WAIVER
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Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create

an actual or implied contract of employment, or to confer any right to remain an employee of Caring Shepherds Healthcare Inc, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Administrator.

Both the undersigned and Caring Shepherds Healthcare Inc, may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I also understand that Caring Shepherds Healthcare Inc has a drug and alcohol policy that prohibits the use of any substances while performing the job.

I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.

I further understand that my employment with Caring Shepherds Healthcare Inc shall be probationary for a period of sixty (60) days, and further

that at any time during the probationary period or thereafter, my employment relation with Caring Shepherds Healthcare Inc, is terminable at will

for any reason by either party.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for

dismissal at any time without any previous notice. I hereby give Caring Shepherds Healthcare inc, previous employers (unless otherwise indicated), references, and others, and hereby release CSHC from any liability as a result of such contract.
Printed Name
Signature of applicant
Date

MonthDayYear
Date
Caring Shepherds Healthcare Inc is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Please return this application to our office at your earliest convenience.
15525 S Park Ave Ste 103B South Holland IL 60473

Phone (708)331-4214 / (815)514-4401 Fax (708)331-4216 / (815)205-4674

info.homemaker@caring-shepherds.com www.caring-shepherds.com
Should be Empty:

Caregiver Employment Application Form

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE

Personal Information

PLEASE COMPLETE ALL QUESTIONS, PAGES 1-4

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

Page 4 of 4