Assured companions at home employment application

Assured companions at home

Employment Application
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What position are you applying for?
Desired hourly pay rate?
What type of employment are you seeking?
Work availability
Shift Availability
Earliest Available Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is highest level of education?
Name of your most recent employer
How long were you employed with this company?
(Month/Year-Month/Year
What were your primary job responsibilities?
Reason for Leaving
Do you have professional caregiving experience?
How many years of experience do you have?
Which of the following caregiving tasks do you have experience performing
Certificates & Training
Do you have reliable transportation?
Are you willing to transport clients?
Do you currently possess a valid driver's license?
Professional Reference #1
Full name/Company name
Relationship to Applicant
Reference Phone Number
Professional Reference #2
Full name/Company name
Relationship to Applicant
Reference Phone Number
May Assured Companions at Home contact the references listed above
If selected for employment, are you willing to complete the background checks and applicable registry screenings required by Assured Companions at Home?
Have you ever been convicted of a felony or misdemeanor?
Please Describe the offense(s) and conviction date(s). Do not include sealed records or information you are not legally required to disclose
Notice Regarding Sealed Juvenile RecordsUnder Nebraska Revised Statute § 43-2,108.05, applicants are not required to disclose sealed juvenile records, including records of arrest, custody, complaints, diversion, adjudication, disposition, or sentencing. Do not include sealed juvenile records when answering the following questions.
Applicant Certification

I certify that the information provided in this employment application is true, accurate and complete to the best of my knowledge. I understand that providing false or misleading information or intentionally omitting material information may result in disqualification from employment or termination if hired.

I understand that submitting this application does not guarantee employment with Assured Companions at Home. If hired as an employee, I understand that employment is at-will, subject to applicable law.
Do you Acknowledge and agree to the Applicant Certification above?
Signature
Should be Empty: