Home Companion Services

HOME COMPANION SERVICES

Application for Employment - STEP-01
Name*
Address

Street

Street Address Line 2

CityState

Zip
Email*
Home Phone
Cell
Best time To Call

AM/PM Option
NYS Drivers License I.D. #
EDUCATION:

Primary SchoolHigh SchoolCollege
EMPLOYMENT INTEREST:

Full TimePart Time
How did you hear of Home Companion Services:
Which days of the week are you available for work?
When can you start work?
Do you have a car?

YesNo
How is your health?

GoodFairPoor
If not good explain:
Any Allergies to food/pets?

YesNo
If so, which?
Any Hobbies?
Have you ever or do you now use recreational drugs?

YesNo
Are you willing to adopt and adapt to our company policies and procedures?

YesNo
Does meeting strangers make you uneasy?

YesNo
Can you make your own decisions promptly?

YesNo
Please describe your work experience and most recent occupation:
Application for Employment (cont’d)
EMPLOYMENT: Please list your employment within the past five years:
Any other helpful information you’d like to tell about yourself?
Print name
Signature of Applicant

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Date:

MonthDayYear
To Whom It May Concern:
The person below has applied to this agency for employment. Our agency is licensed by the State of New York and we would appreciate your help. We would like you to advise us if there is any criminal record on the person indicated below. Information should include any closed files as well, including any sealed records, if possible.

Thank you for your cooperation:
Name

FirstMiddleLast
Also known as
Date of Birth

MonthDayYear
Social Security #
Present address
If less than 5 years previous address:
New York State Driver’s License #
I authorize that any information about can be sent to Home Companion Services of New York, INC. including any sealed records.
Print Name:
Signature of Applicant:

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Date:

MonthDayYear
Company Supervisor
Should be Empty:

HOME COMPANION SERVICES

Application for Employment (cont’d)

To Whom It May Concern: