Clone of Employment Application

Full Name

First NameMiddle InitialLast Name

Address

Street Address

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

Position Applied For:

Available start date:

MonthDayYear

Desired Pay:

Do you have any physical or mental disabilities which may limit your ability to perform essential functions of this job or which would require any special accommodations?

Do you have a valid driver's license?

Are you authorized to work and remain in the United States?

Were you ever discharged or forced to resign from any position?

If Yes, Explain:

Have you served in the U.S. Armed Forces?

If Yes, Branch:

Date Entered Active Duty:

MonthDayYear

Date Released Active Duty:

MonthDayYear

Have you ever been convicted of any violation of the law? (Exclude traffic violations) A conviction will not necessarily disqualify an applicant from the position sought.

If Yes, Explain:

Are you a High School Graduate?

Name of Institution

Did you Graduate?

Do you have additional education to enter?

Additional Type of Education

Name of Instiution

Field of Study

Type of Degree

Did you Graduate?

Type

License or Certificate Number

Date Issued

Expiration Date

MonthDayYear

Caregiver Skills and Years of Experience:

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Supervisor:

Date started

MonthDayYear

Date ended

MonthDayYear

Description of Duties:

Reason for Leaving:

Inquiry may be made of your current and former employers/schools you attended.

May we contact your former employers?

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Supervisor:

Date ended

MonthDayYear

Date started

MonthDayYear

Description of Duties:

Reason for Leaving:

Inquiry may be made of your current and former employers/schools you attended.

May we contact your present employer?

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Supervisor:

Date started

Date

Date ended

Date

Description of Duties:

Reason for Leaving:

Inquiry may be made of your current and former employers/schools you attended.

May we contact your present employer?

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

APPLICANT’S STATEMENT AND AUTHORITY TO RELEASE INFORMATION

(Required for ALL Positions)

I understand that this employment application is not a contract of employment, and any person hired may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are expressly disavowed and should not be relied upon by a prospective or existing employee.

I understand that Prosperity Homecare, LLC may modify, change, or revoke any of its employment policies, pay practices, and benefits without my agreement. I hereby state that all answers on this application are true and understand that falsifying this information can lead to termination if hired.

I UNDERSTAND THAT IN ACCORDANCE WITH Prosperity Homecare, LLC POLICY, FINAL CANDIDATES ARE SUBJECT TO A BACKGROUND CHECK, DRUG TEST, and TB TEST AS A CONDITION OF EMPLOYMENT.

I hereby authorize any and all persons, companies, and/or agencies to release any and all background information, of a confidential or privileged nature, including criminal history, relevant to this application and any pertinent information they may have to the hiring authorities of Prosperity Homecare, LLC.

I release all such parties from all liability of every kind as the result of furnishing the same to Prosperity Homecare, LLC . This information is to be used to assist Prosperity Homecare, LLC in determining my qualifications and fitness for the position I am seeking.

I hereby release Prosperity Homecare, LLC officers, agents and employees from any liability for the use of any and all of the foregoing information, in consideration for being reviewed for the aforesaid position.

Should there be any questions regarding the validity of this release, you may contact me using the information indicated below.

Full Name

DOB:

SSN:

Date

MonthDayYear

Signature

The following information we are soliciting is strictly voluntary. This form will be kept separate and confidential from the application.

Information provided on this form will not be considered in any employment decision but is for statistical purposes only.

Position Applied for:

Date

MonthDayYear

Full Name

First NameLast Name

Gender

Race/Ethnic Origin (Select ONLY One)

How did you learn about this position?

Application for Employment

Education:

Professional License or Certificate, If Required

Skills

Employment History

Personal References

EQUAL EMPLOYMENT OPPORTUNITY QUESTIONAIRE