Entrusted Heart Homecare, LLC 1900 Powell Street, Suite 600, Emeryville, CA 94608 Tel: (510) 225-4020 Email: info@entrustedheart.com
Entrusted Heart Homecare, LLC EMPLOYMENT APPLICATION FORM
Name
First Name
Middle Initial
Last Name
Date
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone no.
Format: (000) 000-0000.
Driver License #
Email
example@example.com
DL Exp date:
Social Security #
Birthday (ID purposes only)
Position Home Care Aide
Type of Employment PRN
Preferred Days and Hours
Currently Employed?
Yes
No
If yes, can we contact employer?
Yes
No
Expected Salary $ per hour
Date Available
Why are you applying for employment in this company?
Are you legally eligible for employment?
Yes
No
Are you available and willing to work overtime if and when required?
Yes
No
Have you applied for a position in this company before?
Yes
No
Do you have any friends or family employed in this branch/location?
Yes
No
Have you been convicted of any crime for the past seven (7) years?
Yes
No
If yes, please give details (i.e. reason for conviction; Note: Conviction does not necessarily mean a loss of employment opportunity)
If hired, will you agree to submit to a criminal background check?
Yes
No
If hired, will you submit a driver's abstract?
Yes
No
N/A
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EDUCATIONAL BACKGROUND (Start from the latest to the earliest)
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School
City, State
Status
Degree/Diploma
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2
Document Checklist
Document Checklist
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
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Month
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Day
Year
Date
End Date
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Month
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Day
Year
Date
Direct Supervisor
Position
Company Email
example@example.com
Telephone no.
Format: (000) 000-0000.
Reason for Leaving
Starting Rate
May we contact for reference?
Yes
No
Final Rate
Summary of Duties, Responsibilities and Achievements
Company:
Telephone no.
Format: (000) 000-0000.
Address:
Job Position:
Start Date
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Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Direct Supervisor
Position
Company Email
example@example.com
Telephone no.
Format: (000) 000-0000.
Reason for Leaving
Starting Rate
May we contact for reference?
Yes
No
Final Rate
Summary of Duties, Responsibilities and Achievements
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REFERENCES (Please ensure that your reference is acquainted with you)
Rows
Name
Job Position
Company/ Address
Phone/ Email Address
Relationship/ Years Acquainted
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2
PLEASE ANSWER THE FOLLOWING QUESTIONS AS EARNESTLY AS POSSIBLE.
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____________________________________________________________________________________ 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.
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