Myers Home Healthcare, LLC

Myers Home Healthcare, LLC
Employment Application Form
Fill out completely. There are 7 Tabs Click on each Tab to enter required information.

Availability - Step 2
Appx. hours per week available:*
Please list days and hours you are available:*
Can you be called at the last minute in case of emergency?*

YesNo

What Education Qualifies You To Work As a Caregiver? - Step 3
High School*
City/State*
Dates*

MonthDayYear
College
City/State
Dates

MonthDayYear
Other
City/State
Dates

MonthDayYear

Training and Skills - Step 4
Degrees/certificates – All Degrees / Certificates must be presented copy. All will be verified with provider/issuer.
Special skills or courses – Any skills that assist in making you qualified as a professional Care Provider.

What is Your Past Experience? - Step 5
Discuss any training or experience working with the elderly. How are you trained and/or experienced in working with the elderly?
What would you like least about working with the elderly?

Employment History - Step 6
Please provide at least three employers or five years of recent, verifiable work history followed by verifiable references.
Company name*
Employed From*

MonthDayYear
Employed To*

MonthDayYear
Job Title*
Reason for leaving*
Duties*
Supervisor*
Supervisor Phone Number*

Area CodePhone Number
Company name*
Employed From*

MonthDayYear
Employed To*

MonthDayYear
Job Title*
Reason for leaving*
Duties*
Supervisor*
Supervisor Phone Number*

Area CodePhone Number
Company name*
Employed From*

MonthDayYear
Employed To*

MonthDayYear
Job Title*
Reason for leaving*
Duties*
Supervisor*
Supervisor Phone Number*

Area CodePhone Number

Business | Professional References- Step 7
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Years Known*
Phone Number*

Area CodePhone Number
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Years Known*
Phone Number*

Area CodePhone Number
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Years Known*
Phone Number*

Area CodePhone Number
Do you have a resume you would like to upload?*

YesNo
Upload your resume*

Upload a File

Cancelof
Electronic Signature*

First NameLast Name
Application Completed*

MonthDayYearHourMinutesAM/PM Option
CERTIFICATION AND RELEASE: I certify that I have read and understand the general requirements of Myers Home Healthecare, LLC on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application as an interested Care Provider and that by submitting this there is no guarantee for employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I also understand that if I accept a postion with Myers Home Healthcare, LLC, it is strickly prohibited to become personally employed by any current or previous client for a period of one hundred and eighty (180) days from our completion of service date. If you are found to be in violation of this agreement, legal actions will be taken against you.
I have read and agree to the above statement*

I agree
Signature

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