Veterans At Home Care Job Application
Applicant Preferred Name
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Social Security Number
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Upload a picture of your Social Security card
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Current Address
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City
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State
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Zip Code
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Home Phone
Cell Phone
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Email Address
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How were you referred to this company?
Positions
What position(s) you are applying for?
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Temporary part-time work - such as summer or holiday work?
Regular part-time work?
Regular full- time work?
What days are you available for work?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What hours are you available for work?
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Can you work evenings?
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Yes
No
Personal Information
Have you ever applied to/work for any of our companies before?
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Yes
No
If hired, would you have transportation to/from work?
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Yes
No
Are you over the age of 18? If under 18, do you have working papers
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Yes
No
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?
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Yes
No
If hired, are you willing to submit to and pass a controlled substance test?
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Yes
No
Have you ever been convicted of a criminal offense (felony or misdemeanor)? If yes please state the nature of the crime(s), when and where convicted, and disposition of the case.
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Education, Training, and Experience
High School
School Name
Address
City
State
Zip Code
Did you graduate?
Yes
No
Degree/ Diploma earned
Yes
No
College/University
College Name
Address
City
State
Zip Code
Did you graduate?
Yes
No
Degree/ Diploma earned
Yes
No
Vocational School
Vocational School Name
Address
City
State
Zip Code
Did you graduate?
Yes
No
Degree/ Diploma earned
Yes
No
Additional Information
Do you have any other experience, training, qualifications, or skills that you feel should be brought to our attention if they make you especially suited for working with us? If yes, please explain below
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Employment History
Are you employed?
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Yes
No
If you are currently employed, may we contact your current employer?
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Yes
No
Name of Employer
Business Type
Address
City
State
Zip Code
Name & Title of Supervisor
Telephone Number
Length of Employment
Positions and Duties
Reason for Leaving
May we contact this employer for references
Yes
No
Employment History Continued
Name of Employer
Business Type
Address
City
State
Zip Code
Name & Title of Supervisor
Telephone Number
Length of Employment
Positions and Duties
Reason for Leaving
May we contact this employer for references
Yes
No
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Reference 1
First and Last Name
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Telephone Number
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Address
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City
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State
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Zip Code
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Occupation
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Number of Years Acquainted
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Reference 2
First and Last Name
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Telephone Number
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Address
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City
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State
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Zip Code
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Occupation
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Number of Years Acquainted
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Reference 3
First and Last Name
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Telephone Number
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Address
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City
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State
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Zip Code
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Occupation
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Number of years Acquainted
*
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Terms and Agreements
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or any document used to secret employment can be grounds for rejection of the application or if I am employed by this company, terms for my immediate expulsion from the company.
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I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice and by either me or the company.
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I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them without giving me prior notice of such disclosure. In addition, I release the company, my former employers, and all other persons, corporations, partnerships, and associations from any claims, demands, or liabilities arising out of or in any way related to such examination or revelation.
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