Emeritus Job Application

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 for signature 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.
Job Applying For:*
Type of Employment:*
Personal Information
Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Are you 18+?*

YesNo

Employment Questions
Date Available to Start:

MonthDayYear
Date
Desired Pay:
Are you currently employed?*

YesNo
Have you ever applied to this company before?*

YesNo
Are you eligible to work in the United States?*

YesNo
Referred By:

Education

Education History

	Name of School	Years Attended	Did you graduate?	Subjects Studied
High School
College
Trade Business, Correspondence Shool
Other

List any medical licenses, awards, certifications, or registrations pertinent to your application:

Employment History (Last 5 Years)
From: *
To:*
Employer:*
Employer:*
Pay:*
Reason for Leaving:*
From:
To:
Employer:
Position:
Pay:
Reason for Leaving:

References

References*

	Name	Title/Relationship	Company Name	Telephone Number
1.
2.
3.
4.

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.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Have you ever been convicted of any law (except a minor traffic violation)?*

YesNo
If Yes, please give details:
Are you now or do you expect to be engaged in any other business or employment?*

YesNo
If Yes, please give details:
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.
Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date

Emergency Contact Information
Primary Contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Secondary Contact:*

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Should be Empty: