ELDACARE HOME HEALTH SERVICES EMPLOYMENT APPLICATION
INSTRUCTIONS:
If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.
Please read "Applicant Note" below.
Complete all pages of this application.
Print clearly. Incomplete or illegible applications may not be accepted.
If more space is needed to complete any question, use the comments section on the back.
The application will be valid for 60 days.
APPLICANT NOTE:
This application form is intended for use in evaluating your qualifications for employment with our Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male:
Female:
What languages do you speak?
*
Name & Phone Number of Person to contact in the event of an emergency:
*
Address:
Out-of-Area:
Have you ever applied here before?
Yes
No
If yes, when?
Have you ever been employed here before?
Yes
No
If yes, when?
How did you hear about our Home Care Agency?
Have you been given a copy of the job description for the position you applied for?
Yes
No
Why are you interested in employment with us?
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QUALIFICATIONS
Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training.
QUALIFICATIONS Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training.
*
Rows
Name and Location of school
Month and Year Attended
Subject Studied
Graduate School
College
High School
License/Certification
State
Exp Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
License/Certification
State
Exp Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have current CPR?
Exp Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Restrictions
Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation?
*
Yes
No.
Other
Please indicate all areas of the city in which you are willing to work:
*
Bucks County
Philadelphia
Montgomery County
Chester County
Delaware
Other
Transportation
Type
*
Private Vehicle
Bus
Bike
Other
Do you have a valid Driver's License?
*
Abuse Investigation
Have you ever been investigated for abuse, neglect, or domestic violence? If "yes", explain:
*
Yes
No
Have you ever pled guilty or no contest or been convicted of a crime? If "yes", explain:
*
Yes
No
Employment History: (List Below the Last 3 Positions, Starting with Most Recent)
*
Rows
From
To
Company and Address
Salary
Reason for Leaving
Duties
1
2
3
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Applicant NOTICE:
It is illegal in Philadelphia for employers to ask about your criminal background during the job application process. Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depends on the results of your background check).
Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting the time of incarceration).
Arrests that did not lead to conviction cannot be used in any employment decisions.
If your background check reveals a conviction, the employer must consider:
The type of offense and the time that has passed since it occurred.
Your job history, character references, and any evidence of rehabilitation.
Its connection to the job you that are applying for; and
Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people.
If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision.
You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.
APPLICANT CERTIFICATION AND RELEASE:
I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.
I understand that any false information, omissions, or misrepresentations of facts in this application may result in the rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.
I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of a drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at will, so that both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
Applicant's Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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EldaCare Home Health Services, Inc. 7106 Castor Ave, Philadelphia, PA 19149. Office: 267-996-4393
APPLICANT REFERENCE CHECK (1)
To Whom It May Concern:
The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
To be filled out by applicant:
Applicant Name:
*
Date of Application:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Employer:
*
Contact Person:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicant's Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
*To be completed by previous employer:
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EldaCare Home Health Services, Inc. 7106 Castor Ave, Philadelphia, PA 19149. Office: 267-996-4393
APPLICANT REFERENCE CHECK (2)
To Whom It May Concern:
The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
To be filled out by applicant:
Applicant Name:
*
Date of Application:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Employer:
*
Contact Person:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
*
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicant's Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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