Application For Employment

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

Full Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

E-mail*

example@example.com

Birth Date*

MonthDayYear

Social Security Number*

Gender*

FemaleMaleNot ListedPrefer not to answer

Ethnicity*

Hispanic or LatinoNot Hispanic or Latino

Race*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Relationship*

Address (City & State)

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Relationship*

Address (City & State)

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Relationship

Address (City & State)

Position Applying For*

Date Available to Start*

Date

Desired Hourly Pay

Have you ever worked for Special Home Care before?*

YesNo

Are you willing to work:*

Evenings?Overnights?Weekends?Overtime?

Your availibility

	SUN	MN	TUE	WED	THU	FRI	SAT
Time

Are you legally eligible for employment in the United States?*

YesNo

Are you 18 years of age or older?*

YesNo

How did you learn about our organization?

Your educational qualifications:*

	School Name	Location of School	Year Completed	Degree	Course of Study
High School
College
Graduate School
Other

Current Employer I*

Name of Current Employer

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Supervisor

First NameLast Name

Start Date*

Date

End Date

Position*

May We Contact?*

YesNo

Previous Employer II*

Name of Previous Employer

Address (City & State)

Position

Reason for Leaving?

Start Date

Date

End Date

Date

May We Contact?

YesNo

Previous Employer III

Name of Previous Employer

Address (City & State)

Position

Reason for Leaving?

Start Date

Date

End Date

Date

May We Contact?

YesNo

Previous Employer IV

Name of Previous Employer

Address (City & State)

Position

Reason for Leaving?

Start Date

Date

End Date

Date

May We Contact?

YesNo

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?*

YesNo

If yes, describe: (Conviction will not necessarily disqualify an applicant from employment. )*

Describe

Are you capable of performing the job set forth in the job description?*

YesNo

If No, which job requirement can you not meet?*

Reference 1 (Name)*

Name of Reference

Relationship*

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address

Reference 2 (Name)*

Name of Reference

Relationship*

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address

Reference 3 (Name)*

Name of Reference

Relationship*

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if
employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.
I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact
and fully discuss my background and history with all persons and entities listed above to give the Agency any, and all information
concerning my previous employment and any information they may have, and release all former employees and others listed above
from all liability for any damage that my result from furnishing the same to the Agency.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my
wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be
considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.

Signature*

Date*

Date

Employment Application

Personal Information:

Emergency Contacts

Emergency Contact 1

Emergency Contact 2

Emergency Contact 3

Availability

Disclosures

Education:

Employment History (Last 5 Years)

Previous Employers

General

References: (References cannot be family members)

Credentials/Specialized Skills & Qualifications/Equipment Operated