APPLICATION FOR EMPLOYMENT
JAD Home Care Services, LLC is an Equal Opportunity Employer. Employment decisions are based on qualifications and business needs without unlawful discrimination.
PLEASE PRINT CLEARLY.
Complete every section. You may attach a resume, but all questions on this application must still be answered.
APPLICANT INFORMATION
Position applying for:
Name (Last, First, Middle):
First Name
Last Name
Other names used, including maiden name or aliases:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone:
Format: (000) 000-0000.
Cell phone:
Format: (000) 000-0000.
Years residing in Missouri:
Email address:
example@example.com
EMPLOYMENT ELIGIBILITY & QUALIFICATIONS
Are you eligible to work in the United States?
Yes
No
Are you 18 years of age or older?
Yes
No
Have you ever been convicted of a crime, including guilty pleas, pleas of nolo contendere, and findings of guilt?
Yes
No
If yes, explain:
Are you listed on the Employee Disqualification List of the Department of Health and Senior Services?
Yes
No
Do you have reliable transportation?
Yes
No
Do you have a valid driver's license?
Yes
No
DL number & state:
Expiration:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you related to a current JAD Home Care employee?
Yes
No
If yes, name and relationship:
Are you a Licensed Nurse?
Yes
No
State, certificate number, and year obtained (Nurse):
Are you a CNA?
Yes
No
State, certificate number, and year obtained (CNA):
AVAILABILITY & RELEVANT EXPERIENCE
Availability:
Weekdays
Weekends
Nights
Evenings
Previous experience with elderly individuals, disabled persons, or children:
Raised children - how long?
Cared for others' children - how long?
Cared for elderly parents - how long?
Cared for other elderly persons - how long?
Cared for disabled person(s) - how long?
Person who can verify this information:
First Name
Last Name
Telephone:
Format: (000) 000-0000.
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JAD HOME CARE SERVICES, LLC
2370 Highway 21, Belleview, MO 63623
(573) 697-1190
EDUCATION & WORK HISTORY
EDUCATION
EDUCATION
Rows
City / State
Graduate?
Years left
Graduation date
Degree
Major
High School
GED
Other School
College
CREDENTIALS & PROFESSIONAL AFFILIATIONS
List credentials, licenses, or professional affiliations relevant to the position:
WORK EXPERIENCE | Begin with your current or most recent employer
Provide your entire work history. List multiple positions with the same organization separately, explain employment gaps, and include full-time military or volunteer commitments. Attach additional sheets if necessary. JAD reserves the right to contact current and former employers for reference information.
EMPLOYER 1
Dates employed: From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment Type
Full time
Part-time
If part-time, hours/week:
Job title:
Organization name and address:
Supervisor name, title, and phone:
Other reference name, title, and phone:
May we contact this employer?
At any time
Only if finalist
Primary duties:
Reason for leaving:
EMPLOYER 2
Dates employed: From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment Type
Full time
Part-time
If part-time, hours/week:
Job title:
Organization name and address:
Supervisor name, title, and phone:
Other reference name, title, and phone:
May we contact this employer?
At any time
Only if finalist
Primary duties:
Reason for leaving:
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WORK EXPERIENCE | Continued
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment Type
Full time
Part-time
If part-time, hours/week:
Job title:
Organization name and address:
Supervisor name, title, and phone:
Other reference name, title, and phone:
May we contact this employer?
At any time
Only if finalist
Primary duties:
Reason for leaving:
ABILITY TO PERFORM ESSENTIAL FUNCTIONS
Are you able, with or without reasonable accommodation, to perform the essential functions of the job for which you are applying? A negative response will not automatically disqualify you.
Yes
No
If accommodation is needed, you are invited - but not required - to describe what you believe could be done to accommodate you:
PROFESSIONAL REFERENCES Please list three
Rows
Full name
Company
Address
Relationship
Telephone
1
2
3
APPLICANT CERTIFICATION & AUTHORIZATION | Please read carefully before signing
I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize JAD Home Care Services, LLC to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. Prior to consideration of employment, I agree to submit to a criminal background records check and closed records check pursuant to Section 610.120, RSMo. I understand that this document is not an offer of employment and that an offer of employment, if tendered, does not constitute a contract for continued or guaranteed employment. I understand that employees of JAD Home Care Services, LLC serve at will, and the employment relationship may be terminated at any time by either party, for any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States and to comply with company and departmental regulations.
Applicant signature:
Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FOR OFFICE USE ONLY
Date of hire:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of termination:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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