Provision Home Care Agency, LLC
APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
Information furnished on this application help to determine your qualification for the type of work for which you have applied. The completion of this application does not guarantee that any positions are open and does not obligate an offer of employment to you. All applications will receive consideration for employment without regard to sex, race, color, national origin, religion, age or handicap in accordance with applicable law.
PERSONAL
Name:
First Name
Middle Initial
Last Name
Date of Application:
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Position Applying For:
Expected Salary:
Social Security No.:
Minimum Acceptable:
Applying For:
Regular Employment
Temporary Employment
Full-Time
Part-Time
Date Available to Start:
-
Month
-
Day
Year
Date
Driver License #:
Date Expires:
-
Month
-
Day
Year
Date
Have You Ever Worked Under Another Name?
Yes
No
If so, what:
Are You Willing To Work:
Days
Evenings
Weekends
Have You Ever Worked For this Company Before:
Yes
No
Are You 18 years of Age or Older:
Yes
No
If Yes; When:
Where:
Position:
Are You Legally Entitled to Work in the U.S.?
Yes
No
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
If You Are Not a U.S. Citizen, Indicate Your VISA or Reg. No.:
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Have You Ever Been Convicted of a Felony?
Yes
No
If Yes, Describe in Detail:
EDUCATION
EDUCATION
Rows
Name and Location
Did You Graduate?
Years Completed
Graduation Completed
Degree(s)
High School
High School
Trade/Business School
Trade/Business School
College/University Undergraduate
College/University Undergraduate
College/University Graduated
College/University Graduated
Other Education
Other Education
SKILLS
IF APPLICABLE TO THE POITION FOR WHICH YOU ARE APPLYING, INDICATE OPERATION AND KNOWLEDGE OF THE FOLLOWING SKILLS:
Diaper Changing
Transfers
Transportation
Sponge/Bed bath
Feeding
PEG tube
Hoyer lift
Dressing
Gait belt
Grooming
Other:
Are You Bilingual?
Yes
No
Languages:
PROFESSIONAL
INDICATE ANY PROFESSIONAL HONORS OR CERTIFICATIONS YOU HAVE RECEIVED (PATENTS, PUBLICATIONS, ETC.):
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Starting with present or most recent, list ALL work experience for the last 10 years. Include self-employment, summer, volunteer, and part-time jobs. If there is a period where not employed, list what you did during that time. Do not leave any time out.
EMPLOYMENT HISTORY
1. Job Title:
Employer:
Employer's Address:
Duties:
Dates of Employment (month / year) From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Starting Salary:
Ending Salary:
Full Time
Part Time
Temporary
Supervisor:
May we contact:
Yes
No
Phone No.:
Format: (000) 000-0000.
Reason for Leaving:
2. Job Title:
Employer:
Employer's Address:
Duties:
Dates of Employment (month / year) From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Starting Salary:
Ending Salary:
Full Time
Part Time
Temporary
Supervisor:
May we contact:
Yes
No
Phone No.:
Format: (000) 000-0000.
Reason for Leaving:
3. Job Title:
Employer:
Employer's Address:
Duties:
Dates of Employment (month / year) From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Starting Salary:
Ending Salary:
Full Time
Part Time
Temporary
Supervisor:
May we contact:
Yes
No
Phone No.:
Format: (000) 000-0000.
Reason for Leaving:
REFERENCES
Rows
ADDRESS
PHONE
TITLE
1.
2.
3.
I hereby state that all the information that I provide on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that Federal Immigration Laws require me to complete an I-9 Form in the regard.
If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite periods, and my employment and compensation may be terminated by the Company (employer) at any time and for any reason whatsoever, with or without good cause at the option of either the Company or myself.
Signature of Applicant
Date
-
Month
-
Day
Year
Date
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