Employment Application

Job Application Form

Please Fill Out the Form Below to Submit Your Job Application!
Instructions: If you need help filling out this application form or any phase of the employment process, please, notify DeVoted Hands Healthcare, LLC 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 be not accepted.
- If more space is needed to complete any question use the section on the back.
Application Note: This application form is intended for evaluating your employment contract qualifications. Please answer all 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 applications 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
Name*

First NameMiddle NameLast NameSuffix
E-mail*
example@example.com
Cell Number*
Alternative Number
Please enter a valid phone number.
Desired Salary $:*
Applied Position*
Emergency Contact *

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Date of Birth*
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a valid Driver's License Number? If yes, please provide your Driver License Number.
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 DeVoted Hands Healthcare LLC?
Have your received a copy of the job description for the position for which you have applied to review?
Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodations?: *
Why are you interested in employment with us?*
Availability
Earliest Possible Start Date*

MonthDayYear
Date
Please, indicate all areas of availability. *

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

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
To
From

Preferences
Please indicate all of the cities in which you are willing to work.
Please indicate the types of services which you are willing to provide*
*In order 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 vech
Are you willing to provide services to a client with a pet?*

NoYes, cats onlyYes, dogs onlyYes, dogs and catsOther
Are you willing to provide services to a client who smokes?*

YesNo
Job Related Skills
Describe training or life skills you have that apply to caring for a senior:*
Describe any work history you have that would apply to caring for a senior:*
What do you like (or think you would like) most about working with older adults?*
Education
Please select your highest grade completed?*

Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12College year1College year 2College year 3College year 4College year 5 +Other

Education History *For employment our minimum education requirement is either a GED or High School Diploma*

	School Name	City, State	Major/Subject	#Yrs Attended	Graduate?
High School
Vocational/Technical School
College/University

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.*

	Current or Most Recent Employer	Most Recent Employer	Third Most Recent Employer
Company Name
City, State
Phone number
Supervisor's Name
Date's Employed (from-to)
Do you currently work for this employer?
Job Title
Duties
Salary ($/hour/week/month)
Reason for Leaving

Military Service

	Military Service
Branch
From
To
Type of Discharge
Rank at discharge

Security
******Please be sure to complete the attached Authorization to do a criminal background check. As a condition of employees must be "Bondable" & "Insurable".
Are you at least 18 years of age?*

YesNo
Have you been charged/convicted of felony and/or misdemeanor and/or served time? If yes, complete the next section.*

YesNo

If you answered "yes" in the section above. please, complete this section.

	Incident	City/State	Charge
1
2
3
4

Please, complete all three references. Your application will not be considered unless references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach at least two references, you will be asked to provide additional references.

References (Do not include relatives)*

	Full Name	Phone Number	Relationship	Number of Years Known
1
2
3

List states and counties of residence for the past seven years.
Cover Letter
Please do not exceed 200 words.
Upload Resume

Cancelof
Any Other Documents to Upload

You can share certificates, diplomas etc.
Cancelof
Preferred Interview Date
PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I certify that the information on the application and its support documents is accurate and complete. I understand an agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize DeVoted Hands Healthcare to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full responses to any inquiries in connection with this employment application. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon a conditional offer of employment. I understand that this document is NOT an offer of employment if tendered, and does NOT constitute a contract for continued guaranteed employment. I understand that employees of DeVoted Hands Healthcare serve at at-will, and the employment relationship may be terminated by either party, for any or no reason, other than a reason prohibited by law. If employed I will be required to furnish proof of eligibility to work in the United States and comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and be ineligible for benefits including paid time off. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.
Applicant's Name*
Type your name
Date*

MonthDayYear
Date
Applicant's Signature*

Powered by Jotform SignClear
Please verify that you are human*
Should be Empty:

Job Application Form

Personal Information

Availability

Job Related Skills

Education

Work History

Security