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  • About Family Healthcare Application

    About Family Healthcare Application

    The completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether to proceed to stage two, the interview, based on this information. About Family Healthcare is an EQUAL OPPORTUNITY EMPLOYER.
  • Today's Date
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  • Format: (000) 000-0000.
  • Date of Birth*
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  • Are you presently employed?
  • Position Applying For:*
  • Location Applying For (Multiple Selections Allowed):*
  • Date Available to work
     - -
  • Are you available to work:*
  • Are you available to work:*
  • Are you available to work:*
  • Do you have your own transportation?*
  • Current Driving License that is valid?*
  • Valid Texas required car insurance?*
  • Would you be willing to provide a driving record?*
  • Any driving accidents in the past three years?*
  • Any driving violations in the past three 3 years?*
  • Are you eligible to work in the U.S.?*
  • How far are you willing to commute?*

  • Data Protection Statement The personal information (data) collected on this form, are used only for the purpose of this employment. Equality of Opportunity Statement The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

  • Companion Skills and Availability Checklist

  • Willing to do live in?
  • Check the job skills you have experience in and will perform:*
  • Check the home medical equipment you are experienced with:*
  • Check the following conditions/diagnosis with which you have experience & job skills to care for a client:*
  • Check the additional skills and protocols you are experience with:*

  • Education - School/College/University

  • Do you have a valid First Aid/CPR Certification?*
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  • Expiry Date
     - -
  • Do you have a valid CNA License?*
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  • Expiry Date
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  • Employment History - 7 years of work

  • May we contact employer(s) listed?*
  • Have you ever been discharged (fired, laid-off, etc.) from a job?*

  • Please fill out the paragraph below with your signature.

  • Dear Employer I,   *   *    ,  *   have applied for a position as a   *   with About Family Healthcare LLC. I understand that they will make a thorough investigation of my entire work history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by About Family Healthcare LLC. I release from liability any person giving or receiving such information.

     

    Signature:  *         Date:   Pick a Date*   

  • Emergency Contact

  • Format: (000) 000-0000.
  • If you are successful in the application, would you require a working permit prior to taking up employment?

  • References

    List the name, relationship, number of years acquainted, and phone number of 3 references who can verify your work experience. Please notify these references that they will be contacted. (No relatives or family friends).

  • Record of conviction does not necessarily disqualify an applicant from employment considerations.

  • Have you ever been convicted of, or plead guilty to, found guilty of, and/or plead to a felony or misdemeanor, except for a minor traffic violation?*
  • Have you ever been charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?*
  • Have you ever had any professional or occupational license or certification suspended/revoked?*
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  • Do you consent to pre-employment background/criminal record check (including all open and closed records)?*

  • Confidentiality Statement


    We consider it an essential practice to uphold the confidentiality of your personal information. We do not allow third parties to gain access to your personal information without your consent. Information that is collected through online forms will be kept confidential.

  • SIGNATURE and DECLARATION

    I understand and agree that: Any material misrepresentation or deliberate omission of a fact in my application may result in refusal of or if employed, immediate termination from employment. Although management makes every effort to accommodate individual preference, business needs may at times make the following conditions mandatory: overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment. It is my understanding that About Family Healthcare LLC will make a thorough investigation of my entire work history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by About Family Healthcare LLC and I release from liability any person giving or receiving such information. I agree that my employment is at will and may be terminated by About Family Healthcare LLC or me at any time with or without notice or cause and without liability for wages or salary except such as may have been earned at the date of such termination. I further understand this is an application for employment and that no employment contract is being offered, nor will any result from my employment with About Family Healthcare LLC. I understand that if I am employed, such employment is for no definite period of time and that About Family Healthcare LLC can change wages, benefits, and conditions at any time.

    I acknowledge that any oral representation or written statements which may have been made to me to the contrary of this paragraph are expressly disavowed and may not be relied upon.

  • Date*
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