INcare Solutions Employment Application

INcare Solutions LLC Employment Application

Please complete the form below to apply for a position with us.
Applying for Position*
Referral Source

AdvertisementRelativeInternetEmployee/ClientOther
If referred by employee or client, please enter their name here:
Full Name*

First NameMiddle NameLast Name
Other Names Used
maiden name, other married names, etc.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long at this address?
If less than 3 years, previous address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list any other address in the past 3 years:
Email Address*
Phone Number*

Area CodePhone Number
Do you send or receive text messages?*

YesNo
Have you previously worked at INcare?*

YesNo
If you have previously worked at INcare, when?
Are you legally eligible to work in the United States (Proof of eligibility is required)*

YesNo
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, motor vehicle check and drug screen. Please check if in agreement (By checking yes, you agree to allow the above described background check)*

YesNo
Do you have reliable transportation to and from work and for travel between worksites, if required?*

YesNo
Do you have any relatives currently employed by INcare? *

YesNo
If yes, please list:
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?*

YesNo
If no, describe the functions that cannot be performed:
EDUCATIONAL BACKGROUND
1. Type of School (High School/GED/College)*
Name/City
How many years attended?

1234
Graduated?*

YesNo
Course or Major
2. Type of School (High School/GED/College)
Name/City
How many years attended?

1234
Graduated?

YesNo
Course or Major
EMPLOYMENT HISTORY

List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experience.
1. Current or most recent employer*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date employed From:*

MonthDayYear
Date employed to:*

MonthDayYear
Position/Title*
Summarize the nature of the work performed and job responsibilities:*
Immediate Supervisor and title:*
Reason for Leaving:*
May we contact for reference/verification?*

YesNoLater
Starting Rate*
Per*

HourYear
Ending Rate*
Per*

HourYear
2. Employer
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date employed from:

MonthDayYear
Date employed to:

MonthDayYear
Position/Title
Summarize the nature of the work performed and job responsibilities:
Immediate Supervisor and title:
Reason for leaving:
May we contact for reference/verification?

YesNoLater
Starting Rate:
Per

HourYear
Ending Rate:
Per

HourYear
3. Employer
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date Employed From:

MonthDayYear
Date Employed To:

MonthDayYear
Position/Title
Summarize the nature of the work performed and job responsibilities:
Immediate Supervisor and title:
Reason for leaving:
May we contact for reference/verification?

YesNoLater
Starting Rate:
Per

HourYear
Comments and other skills, licenses/certification and qualifications:
REFERENCES

List name and telephone number of three professional references that are NOT RELATED to you. If not applicable, list three school or personal references that are not related to you, whom have knowledge of your work ethic, experience and abilities.
1. Reference*
Name
Phone Number*

Area CodePhone Number
Years Known*
Relationship*
2. Reference*
Name
Phone Number*

Area CodePhone Number
Years Known*
Relationship*
2. Reference*
Name
Phone Number*

Area CodePhone Number
Years Known*
Relationship*
I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date. I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of INcare other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s). INcare Solutions is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.*
Enter your name above to indicate you read and agree.
AUTHORIZATION TO RELEASE INFORMATION

In consideration for potential employment and/or employment with INcare Solutions, LLC (“Employer”), Employer will make or will cause an agency on its behalf to make inquiries, including but not limited to, criminal history, public records, experience, or other qualifications for employment, including reasons for termination of past employment. By entering my name below, I authorize, without reservation, any party, including, but not limited to, employers, law enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by Employer or its agent to furnish any or all of the above-listed information. My authorization releases Employer and its agent from any and all liability for damages arising from the investigation and disclosure of the requested information. Further, it releases and discharges all liability from all companies, agencies, officials, officers, employees and other persons, who, in good faith, provide to us the above-mentioned information as requested, in order to successfully complete a background investigation. By entering my name below, I authorize INcare Solutions, LLC to obtain criminal background information on me from the Indiana State Police in accordance with Company policies and contract regulations.
Enter FULL NAME below:
(This is not required; however, a thorough background check is required by 460 IAC Article 6, for ALL employees employed by INcare Solutions, LLC. Therefore, by not signing below, you will not be eligible for employment by INcare Solutions, LLC.)
Information required for background check:
FIRST NAME (This must be your legal name exactly as it is spelled on your Driver's License)*

First NameLast Name
OTHER NAMES USED:*
Maiden name, other married names, etc.
DATE OF BIRTH*

MonthDayYear
RACE*

Native American/AlaskanAsian/Pacific IslanderBlackMulti-RacialWhite
Sex*

MaleFemale
AVAILABILITY

Please list your availability to work for INcare Solutions, providing days of the week and times. We provide services 24 hours a day, 7 days a week. How you complete this form is very important. The work hours that are provided for you by INcare Solutions are driven by two primary business issues; the needs of the clients and your availability to work.
List availability here:
Are you willing to do temporary fill-in hours until the hours you want become available?*

YesNo
Are you willing to work with clients who smoke?*

YesNo
Are you willing to work with clients who have cats?*

YesNo
Are you willing to work with clients who have dogs?*

YesNo
Are you able to work in a multi-level home?*

YesNo
Are you a smoker?*

YesNo
This sheet designates the times that I am committing myself to be available to work for INcare Solutions. By signing this sheet, I acknowledge that the decision to hire me will be based in part on the above availability. I agree any changes to my availability must be approved and signed by my supervisor. I understand that there is no guarantee of hours if I am offered a position with INcare Solutions. I understand that it can take time to reach and sustain my desired number of hours per week and that multiple factors affect this goal including my availability, client requests, my skills, and my ability to please the clients to whom I am assigned. Nothing in this statement is to be construed as a direct, implied or inferred contract of employment.*
Enter your name above to indicate you read and agree
Should be Empty:

INcare Solutions LLC Employment Application

EDUCATIONAL BACKGROUND

EMPLOYMENT HISTORY

REFERENCES

AUTHORIZATION TO RELEASE INFORMATION

Information required for background check:

AVAILABILITY