Employment Application

Open Arms & Hearts Services, Inc.

Employment Application
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

CityState / Province

Postal / Zip Code
Position Applying For
Earliest Start Date:
Are you currently employed?
If employed, may we contact your current employer?
Please describe your caregiving experience, including the types of clients you have worked with (elderly, dementia, disability support, etc.).
Do you have any of the following certifications?
Resume Upload

Cancelof
Certificate Uploads

Cancelof
Education
High School - Name and Location (City, State)
Completed
University/College Undergraduate - Name and Location (City, State)
Degree Completed
University/College Graduate - Name and Location (City, State)
Date Graduated

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Degree Completed
Trade, Business, or Correspondence School - Name and Location (City, State)
Date Graduated

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employment History

Most Recent
Employer
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Salary
Start Date-End Date
mm/dd/yyyy
Job Duties
Employment History
Employer
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Salary
Start Date-End Date
mm/dd/yyyy - mm/dd/yyyy
Job Duties
Employment History
Employer
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Salary
Start Date-End Date
mm/dd/yyyy
Job Duties
Personal References
Please list 3 references (Full name, relation, phone number, years known)
Do you have any physical disabilities that would prevent you from performing the work for which you are applying?
If so, please describe:
Have you ever been injured?
If so, please describe:
Areas of specialized study, research or additional experience:
List the foreign languages you speak:
Do you have any US Military experience:
Separation Rank:
Present Membership in National Guard or Reserves:
Emergency Contact Info
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation
NOTICE TO APPLICANTS:

We comply with the Americans with Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability, to perform job related functions. If you are given a conditional offer of employment, you may be required to complete a post job offer medical history questionnaire and/or undergo a medical examintation. If required, all entering employees in the same job cateogory will be subjected to the same medical questionnaire and/or examination and all information will be kept confidential and in separate files.

We are an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, sex, religion, national origin, handicap, or marital status. We assure you that your opportunity for employment with us depends solely upon your qualifications.
PLEASE READ AND SIGN STATEMENTS BELOW:

I understand that in accordance with Florida Statute 443.131 (3) (a) (2), if hired, I will be placed on a 90 day probationary period. I further understand that if I am terminated for unsatisfactory work performance within the 90 day probationary period, my employer may seek to contest any unemployment benefits I might attempt to obtain as a tesult of my termination.

I understand and agree that all policies, procedures, and the Employee Handbook may be modified, amended, or deleted by my employer with or without notice to me of such amendment, modification or deletion; that the policies and procedures are not intended to be a contract of employment nor do they give me a right of continued employment, and that my employment may be terminated at my option or that the option of my emplover with agreements, or understandings
regarding the terms of employment. There may be no amendments or exceptions to this statement unless they are in writing and signed by the president.

I understand that I may be required to undergo blood and/or urinalysis screening for drug or alcohol use as part of the pre-employment process. In addition, all employees are subject to blood and/or urinalysis screening for drug or alcohol use.

I certify that all information given on this employment application, any resume that I submit to the company, and any related papers and answers given during oral interviews are true and correct.

I understand that my employer will make a thorough investigation of my work and
personal history. I authorize the giving and receiving of any such information requested by my employer during the course of such investigation. I understand that fabrication of any information given by others during the course of this investigation of any derogatory information discovered as a result of this investigation may subject me to immediate dismissal. I hereby release from liability all persons who provide information to my employer during the course of any such investigation.
Signature
Should be Empty:

Open Arms & Hearts Services, Inc.

Education

Employment History

Employment History

Employment History

Personal References

Emergency Contact Info