Golden Valley Home Care Employment Application

Employment Application

Please complete this form accurately to demonstrate your suitability for the position. Our agency is an equal opportunity employer and does not discriminate based on race, creed, color, gender, age, national origin, disability, or military status. All applicants are considered for employment, advancement, and development based on skills, performance, and potential. All information provided will remain confidential and is protected under HIPAA regulations. To complete your application, please upload a valid ID, Social Security card, and a TB test completed within the past 365 days.
Name:*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Phone Number:*
E-mail Address:*
example@example.com
Social Security Number*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Name / Relationship):*
Emergency Contact Phone Number:*
Please enter a valid phone number.
Upload Resume:

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Country of Birth *
State / Province of Birth*
How many hours a week are you available to work?*
Position applying For?*
Name of client you would like to work for & relationship (If Applicable)?

Job Skills & Education
Training or Certifications/Licenses:
High School (Name / Location):*
College If Applicable (Name / Degree):
References

Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*
Relationship:*
Years Known:*
Reference 2
Name:*

First NameLast Name
Phone Number*
Relationship:*
Years Known:*
Was your last name different from your present name during the above listed jobs?*

YESNO
If yes, what was your name?
Do you have reliable transportation?

YESNO

Employment

List last two jobs you were employed at starting with the most recent
Most Recent Job*
Second Most Recent Job*
Have you ever been convicted of a crime in the past 10 years, barring employment in a Home Care and community support Agency?*

YESNO
If Yes, Please List Conviction(s)/ Date(s)/ Location (s)
Are you capable of performing the duties set forth in the job description?*

YESNO
If you answered No, which job requirement can you not meet?
Language Skills Other Than English : Written/Spoken

Upload Driver's License Or Identification Card*

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Upload SSN Card*

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Upload TB test you've completed in the past 365 days*

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Upload an image or pdf of your Voided Check or Bank Statement with Routing Number and Account Number

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Should be Empty: