EMPLOYMENT APPLICATION
Date:
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Month
-
Day
Year
Date
PERSONAL INFORMATION
Full Name:
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Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number:
*
Date of Birth:
*
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Month
-
Day
Year
Date
Cell Phone:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Home Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
What languages are you fluent in?
*
Do you have a Valid Driver's License?
*
Drivers License Number
*
Do you currently have a vehicle?
*
Make & Model:
*
Do you currently have valid car insurance?
*
Are you willing to provide duties in your vehicle?
*
Have you had a BCI or FBI fingerprint background check in the last year?
*
If you answered YES, please provide the month and year of your last fingerprints:
QUALIFICATIONS
QUALIFICATIONS
Rows
School Name
City, State
Graduate? Y/N
Major/ Course
High School GED
College
Vocational/ Technical
AVALIBILITY
What is the earliest date you can begin working?
*
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Please provide your availability:
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Weekends
Weekdays
Mornings
Afternoons
Evenings
Overnights
Please provide the times of your availability:
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
From:
To:
Do you have any of the following?
CPR/First Aid:
*
Medication Administration Certification 1, 2 or 3:
*
De-escalation Training:
*
Do you have any of the following? (cont'd)
CNA:
STNA:
Interpreter:
Do you have any additional certifications or licenses not listed?
PREFERENCES
Are you willing to work with a client who has a cat?
*
Are you willing to work with a client who has a dog?
*
Are you willing to work with a client that does not speak English?
*
Are you willing to provide services to a client that smokes?
*
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Which counties are you willing to work in?
*
Hamilton
Butler
Warren
Clermont
Which of the following duties do you have experience in?
*
Bathing
Grooming
Housekeeping
Dressing
Laundry
Oral Care
Meal Preparation
Shopping
Shopping
Medication Reminders
Transportation
Feeding Tubes
Companion Care
Community Outings
Bowel Care
Entertainment
Bladder Care
Socialization
Ambulation
Other:
Are they any duties or activities of daily living which you are not willing/able to perform?
*
BACKGROUND
Have you ever been convicted of a Felony?
*
Do you have 6 or more points on your driving record?
*
Please list the states you have lived in for the past seven years:
*
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EMPLOYMENT HISTORY
Most Recent Employer:
Employer Name:
*
City:
*
State:
*
Phone:
*
Format: (000) 000-0000.
Are you still working for this employer?
*
Starting Salary:
*
Ending Salary:
*
Reason for leaving this employer:
*
Second Most Recent Employer:
Employer Name:
*
City:
*
State:
*
Phone:
*
Format: (000) 000-0000.
Are you still working for this employer?
*
Starting Salary:
*
Ending Salary:
*
Reason for leaving this employer:
*
STATEMENT OF AUTHORIZATION
Please read the information on this form carefully and completely.
I have applied for employment with Honorworth Homecare LLC and have provided information about my previous employment. I authorize Honorworth Homecare LLC to conduct a reference check with my present and/or previous employer(s).
I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary, and employment history. My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment with Honorworth Homecare LLC, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Honorworth Homecare LLC from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Honorworth Homecare LLC. I further authorize Honorworth Homecare LLC to obtain feedback and references from my supervisors over the course of my employment with Honorworth Homecare LLC. I understand that subsequent and continued employment with Honorworth Homecare LLC may be subject to this feedback. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
Signature of Employee
*
Employees Name- Printed
*
Date
*
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Month
-
Day
Year
Date
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EQUAL OPPORTUNITY EMPLOYER
It is the policy of Honorworth Homecare LLC, in accordance with all applicable laws, to recruit, hire, train, and promote persons in all job titles without regard to race, color, national origin, genetic information, religious beliefs, sex, gender identity, sexual orientation, age, marital status, pregnancy, disability, protected veteran status, or any other protected classifications, activities, or conditions as required by federal, state and local laws.
All employment decisions shall be consistent with the principle of equal employment opportunity, and only valid qualifications will be required.
By signing in the space provided below, you hereby acknowledge that you have been given a copy of the Honorworth Homecare LLC's Equal Opportunity Employer Statement and, that you have read the Statement and that you understand its contents.
Signature of Employee
*
Employees Name- Printed
*
Date
*
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Month
-
Day
Year
Date
CERTIFICATION
I certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that falsified statements on this application in any detail shall be considered sufficient cause for disqualification from further consideration for hire or for dismissal. 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.
I also understand that due to the nature of the business, no amount of work can be guaranteed.
By signing in the space provided below, you hereby acknowledge that you have read the Statement above and that you understand its contents and agree to its contents.
Signature of Employee
*
Employees Name- Printed
*
Date
*
-
Month
-
Day
Year
Date
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AT WILL EMPLOYEMENT
Honorworth Homecare LLC is an At Will Employer.
This means that during the course of employment with the Honorworth Homecare LLC, employees are free to terminate their employment with the Honorworth Homecare LLC at any time, with or without a reason, and the Honorworth Homecare LLC has the right to terminate employees at any time, with or without a reason. Although the Honorworth Homecare LLC may choose to terminate an employee for cause, cause is not required.
No one other than the Owner of the Honorworth Homecare LLC has the authority to alter this at-will employment arrangement, to enter into an agreement for employment for a specified period of time, or to make any agreement contrary to this at-will arrangement. Furthermore, any such agreement must be in writing and must be signed by the Owner of Honorworth Homecare LLC.
I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of criminal background check. My signature below acknowledges that I have read, understand, and agree to the above disclosure.
By signing in the space provided below, you hereby acknowledge that you have been given a copy of the Company's Statement and Acknowledgement of At-Will Employment, that you have read the Statement and that you understand its contents, and that you further understand that the Statement supersedes any and all previous agreements, policies, practices or guidelines, whether oral or written.
Signature of Employee
*
Employees Name- Printed
*
Date
*
-
Month
-
Day
Year
Date
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