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.
- Full Name
  
  First NameLast Name
- Present Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Phone Number
  
  Area CodePhone Number
- Date of Birth?
- Length of time you have resided in the general area?
- Martial Status?
- Do you smoke?
- Are you a U.S. Citizen or are you authorized to work in the U.S.?
- Have you been hospitalized or treated for any serious injury, illness, accident or other physical condition in the past five(5) years?
- Do you know of any physical, mental or other type of disability or limitations that may prevent you from performing any job you might otherwise be eligible to hold?
- If yes explain
- How did you hear about this opening?
- Alternate Contact
- Full Name
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Relationship
- Are you currently employed / provide Care to others?
- Have you ever been convicted of a misdemeanor/felony? If Yes, provide details
- Details
- Do you have dependable transportation?
- Driver Lic #
- Auto Insurance Company
- 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?
- High School
- City/State
- Dates
  
  MonthDayYear
- College
- City/State
- Dates
  
  MonthDayYear
- Other
- City/State
- Dates
  
  MonthDayYear
- 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.
- 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?
- 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
- 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?
- 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
- Signature
- Should be Empty: