California Application

EDUCATIONAL BACKGROUND (Start from the latest to the earliest)

Rows	School	City, State	Status	Degree/Diploma
1
2

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Rows	Date Completed	Current
CPR & First Aid
TB Screening
HCA Registry

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EMPLOYMENT HISTORY
Company:
Telephone no.
Format: (000) 000-0000.
Address:
Job Position:
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Direct Supervisor
Position
Company Email
example@example.com
Telephone no.
Format: (000) 000-0000.
Reason for Leaving
Starting Rate
May we contact for reference?
Final Rate
Summary of Duties, Responsibilities and Achievements
Company:
Telephone no.
Format: (000) 000-0000.
Address:
Job Position:
Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Direct Supervisor
Position
Company Email
example@example.com
Telephone no.
Format: (000) 000-0000.
Reason for Leaving
Starting Rate
May we contact for reference?
Final Rate
Summary of Duties, Responsibilities and Achievements
3 of 5

REFERENCES (Please ensure that your reference is acquainted with you)

Rows	Name	Job Position	Company/ Address	Phone/ Email Address	Relationship/ Years Acquainted
1
2

What was the best job you had? Why?
Why is it important to follow the Service Care Plan on each client?
What qualities and attitude did your best supervisor have?
Describe a situation when a client was upset or resistant to care. How did you handle it?
What is the most challenging aspect of private home care?
How will you contribute to the company?
How do you deal with rude and impatient customers especially when you are nearing the end of a long and tiring shift?
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I do hereby certify that all the information I have provided above are all complete,

true, and accurate to the best of my knowledge.
I understand that the information contained herein, and any attached documents

hereto are classified confidential and exclusive for Entrusted Heart Homecare, LLC

use, and thus is not shared nor to be shared with any third party. The information is

to be used by Entrusted Heart Homecare, LLC as one of the bases for decision-making

during the application and hiring process. By signing this application, I understand

that I am giving due authority to Entrusted Heart Homecare, LLC to obtain, document

and file all the information herein and use it for the abovementioned purpose.
I also hereby give Entrusted Heart Homecare, LLC authorization to review the

truthfulness of all my statements herein this application form. I understand that any

false statements or deliberate omissions on this document or in any other document I

am attaching may serve as grounds for disqualification, and/or if discovered ruing the

employment term, may serve as a reason for disciplinary action up to and including

my dismissal.
I also understand that if hired, I am required by Entrusted Heart Homecare, LLC to

submit to a criminal background investigation which will include proof of identity,

license to work in the State of California, documents certifying educational and

training background, as well as driver's license, all at my own expense. I also consent

to a motor vehicle record check if required.
I have read, understood, and I agree that once I am employed, Entrusted Heart

Homecare, LLC reserves the right to terminate my employment at any point of any

time regardless of any or lack of cause, with or without prior notice, as I am free to

resign at any point regardless of any or lack of cause, with or without prior notice,

unless as required by the law.
I fully understand that my application does in no way represent any employment contract or agreement.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Entrusted Heart Homecare, LLC EMPLOYMENT APPLICATION FORM

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EMPLOYMENT HISTORY