Employee Application

EMPLOYMENT APPLICATION FORM
Date

MonthDayYear
Date
Last
First
Middle
Street
City
State
ZIP
Telephone no.
Cellphone no.
Email
example@example.com
Referred by
Birthday
Position

Home Care AideOther
Type of Employment

PRN
Preferred Days and Hours
Currently Employed?

YesNo
Date Available

MonthDayYear
Date
Expected Salary
Why are you applying for employment in this company?
Are you legally eligible for employment?

YesNo
Are you available and willing to work overtime if and when required?

YesNo
Have you applied for a position in this company before?

YesNo
Have you been convicted of any crime for the past seven (7)

YesNo
If yes, please give details (i.e. reason for conviction; Note: Conviction does not necessarily mean a loss of employment opportunity)
If hired, will you agree to submit to a criminal background check?

YesNo
Do you have a Drivers License?

YesNo
Do you have a Car?

YesNo
If hired, will you submit a driver’s abstract?

YesNoN/A
Entrusted Heart Homecare, LLC 1900 Powell Street, Suite 600, Emeryville, CA 94608 Tel: (510) 225-4020 Email: info@entrustedheart.com
EDUCATIONAL BACKGROUND
(Start from the latest to the earliest)
School
City, Region, State
Degree
Status

GraduateUndergraduate
School
City, Region, State
Degree
Status

GraduateUndergraduate
LICENSES AND CERTIFICATIONS
(Start from the most related to the position you wish to apply)
Type of License/ Accreditation
Latest Registration Date
State Coverage

	Date	Yes	No
CPR & First Aid
TB Screening
HCA Registry

PLEASE UPLOAD ALL FILES BELOW

Cancelof
EMPLOYMENT HISTORY
(Please start from the most recent)
Company
Telephone no.
Job Position
Start Date

MonthDayYear
Date
End Date
Direct Supervisor
Telephone no.
Reason for Leaving
May we contact for reference?

YesNo
Final Pay Rate
Summary of Duties, Responsibilities and Achievements
Company
Telephone no.
Job Position
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Direct Supervisor
Telephone no.
Reason for Leaving
May we contact for reference?

YesNo
Final Pay Rate
Summary of Duties, Responsibilities and Achievements
Entrusted Heart Homecare, LLC 1900 Powell Street, Suite 600, Emeryville, CA 94608 Tel: (510) 225-4020 Email: info@entrustedheart.com
REFERENCES
Reference 1
Reference 2
PLEASE ANSWER THE FOLLOWING QUESTIONS AS EARNESTLY AS POSSIBLE.
What was the best job you had? Why?
Why is it important to follow the Service Care Plan on each client?
What qualities and attitude did your best supervisor have?
Describe a situation when a client was upset or resistant to care. How did you handle it?
What is the most challenging aspect of customer care? What about private home care?
How will you contribute to the company?
How do you deal with rude and impatient customers especially when you are nearing the end of a long and tiring shift?
Entrusted Heart Homecare, LLC 1900 Powell Street, Suite 600, Emeryville, CA 94608 Tel: (510) 225-4020 Email: info@entrustedheart.com
I,
, do hereby certify that all the information I have provided above

are all complete, true, and accurate to the best of my knowledge. I understand that the information contained herein, and any attached documents hereto are classified confidential and exclusive for Entrusted Heart Homecare, LLC use, and thus is not shared nor to be shared with any third party. The information is to be used by Entrusted Heart Homecare, LLC as one of the bases for decision-making during the application and hiring process. By signing this application, I understand that I am giving due authority to Entrusted Heart Homecare, LLC to obtain, document and file all the information herein and use it for the abovementioned purpose. I also hereby give Entrusted Heart Homecare, LLC authorization to review the truthfulness of all my statements herein this application form. I understand that any false statements or deliberate omissions on this document or in any other document I am attaching may serve as grounds for disqualification, and/or if discovered ruing the employment term, may serve as a reason for disciplinary action up to and including my dismissal. I also understand that if hired, I am required by Entrusted Heart Homecare, LLC to submit to a criminal background investigation which will include proof of identity, license to work in the State of California.
documents certifying educational and training background, as well as driver’s license, all at my own expense. I have read, understood, and I agree that once I am employed, Entrusted Heart Homecare, LLC reserves the right to terminate my employment at any point of any time regardless of any or lack of cause, with or without prior notice, as I am free to resign at any point regardless of any or lack of cause, with or without prior notice, unless as required by the law. I fully understand that my application does in no way represent any employment contract or agreement.
Date

MonthDayYear
Date
Signature/Printed Name

Clear
Entrusted Heart Homecare, LLC 1900 Powell Street, Suite 600, Emeryville, CA 94608 Tel: (510) 225-4020 Email: info@entrustedheart.com
Entrusted Heart Homecare, LLC
CRIMINAL BACKGROUND CHECK
Candidate’s Name
Candidate’s Title
Social Security Number
DOB

MonthDayYear
Date
Do you give Entrusted Heart Homecare, LLC permission to check Criminal Background Check?

YesNo
Do you give Entrusted Heart Homecare, LLC permission to check Motor Vehicle Record?

YesNo
Driver License Number
State License Issued
License Expiration Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Entrusted Heart Homecare, LLC 1900 Powell Street, Suite 600, Emeryville, CA 94608 Tel: (510) 225-4020 Email: info@entrustedheart.com
Should be Empty:

EMPLOYMENT APPLICATION FORM

EDUCATIONAL BACKGROUND

LICENSES AND CERTIFICATIONS

EMPLOYMENT HISTORY

REFERENCES

Entrusted Heart Homecare, LLC

CRIMINAL BACKGROUND CHECK