• 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:*
     - -
  • Are you 18+?*
  • Primary Language Spoken*
  • English Proficiency*

  • Employment Questions

  • Date Available to Start:*
     - -
  • 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:
     - -

  • Education

  • Rows

  • Employment History

    Please list at least a minimum of 5 years of work history.
  • Rows

  • 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*
     - -
  • 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*
     - -

  • 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:*
  • Rows

  • Background Check Authorization Form

    All information will be kept strictly confidential
  • Date of Birth:*
     - -
  • Race:*
  • Sex:*
  • Is Mailing Address same as Permanent Address?*
  • Date of Expiration
     - -
  • 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*
     - -

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Should be Empty: