New Hire Family's Safe Haven Package Form

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Employment Application

Family's Safe Haven Companion Care LLC
Welcome to Family's Safe Haven Companion Care. We look forward to working with you and hope you enjoy your working experience with us.
- Please complete the required areas (marked with a red asterisk * ) throughout the packet.
- When finished, you will need to electronically submit this packet by clicking on Submit at the end. An option to print a copy of this form is available at the end.
- You will also need to provide the following before your first day on the job
  - Social Security Card, Birth Certificate, or Passport
  - Fill and sign your completed W-9
- All items must be submitted to your Manager before you begin working your first shift. Late items will result in a delayed paycheck.
- Please contact Adrianna Pasquale (609)618-4787 if you have any questions about your employment with Family's Safe Haven.
Personal Information
Name

First NameLast Name
Social Security Number
XXX-XX-XXX
Personal Email
example@example.com
Cell Number

Area CodePhone Number
Home Number

Area CodePhone Number
Personal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Ethnic Origin
Disabled
Veteran
Please list at least 2 references below. Please limit to only one personal reference.
Reference 1 *
Reference 2 *
Reference 3
Reference 4
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Relationship to Self
What is the best way to contact them in the event of an emergency?
Please provide phone numbers, specifically the number they are best to be contacted on.
Cell Number

Area CodePhone Number
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Miscellaneous Information
Have you been convicted of any felonies?
If you answered YES, please provide details
First NameLast Name
What are the days of the week you are available to work?
Days of the week (M,Tu,W,Th,F,Sa,Su)
What hours of the day are you available to work?
Ex: 8am-12pm, 4pm-8pm
Are there days of the week or hours in a day that you cannot work due to school, family obligations or other employment?
Date Signed

MonthDayYear
Date
Hours Worked

Please note that your pay will be prorated. If you work 45 minutes, you will be paid for 45 minutes, and not for a full hour.
CLIENTS/CASES

Please note that if you choose to terminate your employment with Family's Safe Haven Companion Care LLC, we politely request 2 weeks notice as a courtesy. In addition, if you leave the company, you are not permitted to take clients with you. If you try to take on any patients, legal actions will be taken.
Applicant's Signature
Date Signed

MonthDayYear
Date
Type a question
Should be Empty:

Employment Application

Personal Information

Please list at least 2 references below. Please limit to only one personal reference.

Emergency Contact Information

Miscellaneous Information

Hours Worked

CLIENTS/CASES