Employment Application Form

Employment Application

Please complete the form below to apply for a position with us.
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Position Applied For*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you legally eligible to work in the US?*
Have you ever been employed or have any family and friends at this company? If yes, please specify when and why did you leave and state family and friends.*
Have you been convicted of a crime in the last (7) years? (conviction will not be a deciding factor in the pre-screening process or employment)*
During the hiring process, do you agree to provide a criminal background check? (a criminal fingerprint background check is required)*
During the hiring process, do you agree to a Motor Vehicle Report check when needed?*
Available Start Date*

MonthDayYear
Please specify DAYS and HOURS Available to work.*
Are you available for call outs if needed?*
How did you hear about us*

Please List Current and Former Employment

Please show at least (1) one year of combined experience
Current or Last Employer*

Company

Street Address

CityState / Province

Postal / Zip Code
Job Title blanks* Salary Rate blank*
Still employed? Type a label* Reason for leaving Type a label*
Former Empoyer

Company

Street Address

CityState / Province

Postal / Zip Code
Job Title blanks Salary Rate blank
Still employed? Type a label Reason for leaving Type a label
Former Employer

Company

Street Address

CityState / Province

Postal / Zip Code
Job Title blanks Salary Rate blank
Still employed? Type a label Reason for leaving Type a label

Please list 2 Professional References

(no family members please)
Do you have any of the following licenses or certifications?*

CNA CertificationPCA CertificationCPR CertificationFirst Aid CertificationRN LicenseLPN LicenseDrivers LicenseOther
Please upload a copy of all licenses and certifications stated above

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Upload Your Resume

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What do you think is the most difficult part of caregiving?*
In what situations do we provide services not listed in the SERVICE/CARE PLAN?*
What does DNR mean?*
**CERTIFICATION AND RELEASE: I certify that I have read and understand the application 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 misrepresentation of facts called for 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 consumers reporting bureaus, to verify any 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 understand that I am not obligated to disclose sealed or expunged records of conviction or arrest.

I also understand that the use of illegal drugs is prohibited during
employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs before and during employment.

Lynette’s TLC Home Services LLC is an equal opportunity employer. We strive to promote equality and diversity within the Agency, and this policy applies to all our employees, job candidates, volunteers, and contractors as well. Being an equal opportunity employer means we do not discriminate in employment on basis of nationality, color, sex, age, disability, religion, sexual orientation, and any other means as protected by all applicable state and federal laws.
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Employment Application

Please List Current and Former Employment

Please list 2 Professional References