• Job Application for Employment

    Emeritus Home Care

  • Emeritus Home Care Does not discriminate in hiring or employment based on race, color, religion, national origin, age, sex, disability, sexual orientation, Vietnam era
    military service, or any other basis on which discrimination is prohibited by federal, state, or local laws. No questions on this application are intended to secure information to be used for such discrimination.


    Each question should be answered fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if
    you do not have enough room on this application. PLEASE PRINT, except fors ignature on back of application. In reading and answering the following questions, please be aware that none of the questions are intended to imply illegal preference or discrimination based upon non-job-related information.

  • Personal Information

  • Format: (000) 000-0000.
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you 18+?*
  • Primary Language Spoken*
  • English Proficiency*

  • Employment Questions

  • Date Available to Start:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently employed?*
  • Have you ever applied to this company before?*
  • Are you legally authorized to work in the United States?*
  • Will you now or in the future require employer sponsorship for employment authorization (for example, H-1B visa, work permit renewal, etc.)?*
  • What is your current work authorization status?*
  • If applicable, please indicate the expiration date of your current work authorization:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Education

  • Education History
    Rows

  • Employment History

    Please list at least a minimum of 5 years of work history.
  • Please list at least a minimum of 5 years of work history or background (e.g., stay at home mom or babysitter)*
    Rows

  • References

  • References*
    Rows

  • I hereby authorize Emeritus Home Care to contact my current/former employers which I have provided. I give my permission to release any information deemed necessary for the purpose of evaluating me for possible employment.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever been convicted of any law (except a minor traffic violation)?*
  • Are you now or do you expect to be engaged in any other business or employment?*

  • Acceptance of this application affords no assurance of eventual employment. If employed, you will be required to verify your ability to legally accept employment
    in the United States. For certain jobs, background investigations, to include contacting former employers, may be required. This application does not constitute a contract of employment. Employment and compensation can be terminated with or without notice, and with or without cause, at any time.


    I have read the foregoing instructions and questions and to the best of my knowledge my answers are true and correct. I have not knowingly misrepresented or withheld any fact or circumstance that would, if disclosed, affect my application unfavorably. I understand that misrepresentation of any of the above may be caused
    for termination.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Employment Availability

  • Do you have your own motor vehicle?*
  • Do you have any allergies that would affect your work?*
  • Do you have a problem working with a client who smokes?*
  • Locations (counties) willing to work:*
  • Days Available
    Rows

  • Background Check Authorization Form

    All information will be kept strictly confidential
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Race:*
  • Sex:*
  • Is Mailing Address same as Permanent Address?*
  • Date of Expiration
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is there anything in your lifestyle or background that would call into question your ability?*

  • I hereby authorize Emeritus Home Care To make an independent investigation of my background and criminal or police records. I release Emeritus Home Care and any person or entity which provides information pursuant to this authorization, from all liabilities, claims, or lawsuits regarding the information obtained from all the above sources. The information contained in this application is correct to the best of my knowledge. I understand that any omission of material fact on this application may be grounds for rejection of this application.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Pre-Employment Health Assessment

    Emeritus Home Care

  • This form is used to determine whether a prospective employee is physically able to safely perform the essential duties of a Personal Care Aide or Companionship position.

    Completion of this form is required after a conditional offer of employment and will be kept confidential in accordance with HIPAA, ADA, and EEOC regulations.

    Agency Name: Emeritus Home Care

    Address: 1400 Buford Hwy, Suite D-3, Buford, GA 30518

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Position Applied For*
  • Expected Work Setting*

  • Typical Duties May Include:

    • Assisting with bathing, dressing, grooming
    • Toileting and incontinence care
    • Transfers and mobility assistance
    • Meal preparation and feeding assistance
    • Medication reminders (non-clinical)
    • Light housekeeping
    • Companionship
    • Monitoring client condition and reporting changes

  • Essential Physical Job Requirements

  • Please indicate whether you are able to perform the following job tasks with or without reasonable accommodation.*
    Rows

  • If you answered No to any item, please explain and indicate whether accommodation may allow you to perform the task.

  • Current Health Status

  • Communicable Disease Screening

    Note: A TB screening or test will be required prior to employment per state health regulations.
  • Do you currently have or have you recently had:*
    Rows

  • Work Safety

  • Do you have any condition that may cause:*
    Rows

  • Medication Disclosure

  • Confidentiality Notice

    All medical information obtained through this form will be maintained in a confidential medical file separate from personnel records and will only be used to determine the employee’s ability to safely perform job duties in accordance with ADA and EEOC regulations. 

  • Employee Certification

  • Should be Empty: