Just Like Family Home Care Employment Application

  • Just Like Family Home Care Employment Application

    907 Grinnell Ave SW Orting, Washington 98360
  • Date of Birth*
     / /
  •  -
  • What date are you available to start work?
     - -
  • Desired Employment:*
  • Days Available:*
  • Are you available to work Holidays?*
  • Available to work overtime?*
  • Do you have any restrictions on available shifts?*
  • Are you eligible to work in the United States?*
  • Do you have any conditions which would require job accommodation?
  • Have you been convicted of a Criminal offense within the last five years*
  • Do you currently have any type of pending charges?*
  • Are you willing to complete a mandatory background screening?*
  • Are you willing to complete a mandatory drug test?*
  • Do you have a valid driver's license?*
  • Do you have reliable transportation to and from work?*
  • Do you have active Auto Insurance?*

  • Skills / Qualifications: ( Licenses, Skills, Training, Awards)

  • Do you have an active HCA, CNA, or NAR certificate?*
  • Do you have a current Food Handlers Certification?*
  • Do you have a current CPR / First Aid Card?*

  • Education & Military Service:

  • Are you a member of the Armed Services?
  • Are you a member of the Armed Services?
  • If discharged, was it an Honorable Discharge?

  • Employment History:

    (Please list last 3 years total employment, use back of sheet if necessary)

  • Employer Name:   *   
    Address & Phone:   *      
    Wage:   *   
    Quit?    *   
    Dates Employed:   *   
    Position:   *   
    May we contact this employer?      *   
    If no, why?      

  • Employer Name:   *      
    Address & Phone:     *   
    Wage:      *   
    Quit?         *   
    Dates Employed:    *     
    Position:      *   
    May we contact this employer?      *         
    If no, why?         

  • Employer Name:*
    Address & Phone: *
    Quit?      *   
    Dates Employed:   *   
    Position:   *   

  • References:

    (Please list 3 PROFESSIONAL & 3 PERSONAL references)

  • Please read and sign the following disclaimer to submit for consideration. If your application is successful, theinformation given will become part of your permanent employment file. We will reach out to you via phone or email afterverification of said references.

  • Diclaimer:

  • I,    * , authorize Just like Family Home Care, LLC to obtain employment verification from ANY AND ALL of my previous employers listed above as determined necessary for the position I am applying for. I further understand that this form is used to obtain information from previous employersregarding my employment dates, rate of pay, attendance, and whether I am considered re-hirable or not. I certify that all the information contained in this application is true and complete. I understand that false information maybe grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above. This includes work history and reference verifications.

  • Date:
     - -
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  • Should be Empty: