EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Position Applying For*
Date Available to Start*

MonthDayYear
Desired Salary*
Per Hour Rate
Are you a citizen of the United States?*

YESNO
If no, are you authorized to work in the United States?*

YESNON/A
Have you ever worked for this company?*

YESNO
If yes, please indicate when.
- Name of High School *
- Address of High School
- Dates Attended High School (From-To)*
- Dates Attended (Date Started)
  
  MonthDayYear
- Dates Attended (Date Ended)
  
  MonthDayYear
- Did you graduate?*
  
  YESNO
- Name of College
- Address of College
- Dates Attended College (From-To)
- Dates Attended College (Date Started)
  
  MonthDayYear
- Dates Attended College (Date Ended)
  
  MonthDayYear
- Did you graduate?
  
  YESNO
- Degree Obtained (If Applicable.)
- Other Education / Training
- Address of Education/Training
- Dates Attended College (Date Started)
- Dates Attended (Date Started)
  
  MonthDayYear
- Dates Attended (Date Ended)
  
  MonthDayYear
- Type of License/Certification
- License/Certificate#
- State Issued
- Type of License/Certification
- License/Certificate#
- State Issued
- Employer Name*
- Employer Address*
- Full Name of Employer Contact/Supervisor*
  
  First NameLast Name
- Employer Contact Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Your Job Title*
- Your Starting Salary*
  Per Hour Rate
- Your Current or Ending Salary*
  Per Hour Rate
- Duties & Responsibilities*
- Dates of Employment (From - To)*
  If currently employed, indicate From - Present.
- Dates of Employment (Date Started)*
  
  MonthDayYear
- Dates of Employment (Date Ended)*
  
  MonthDayYear
- Currently Working Here?*
  
  YESNO
- Reason for Leaving (If currently working here, enter N/A.)*
- May we contact this employer for a reference?*
  
  YESNO
- Employer Name*
- Employer Address*
- Full Name of Employer Contact/Supervisor *
  
  First NameLast Name
- Employer Contact Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Your Job Title*
- Your Starting Salary*
  Per Hour Rate
- Your Current or Ending Salary*
  Per Hour Rate
- Duties & Responsibilities*
- Dates of Employment (From - To)*
- Dates of Employment (Date Started)
  
  MonthDayYear
- Dates of Employment (Date Ended)
  
  MonthDayYear
- Currently Working Here?*
  
  YESNO
- Reason for Leaving (If currently working here, enter N/A.)*
- May we contact this employer for a reference?*
  
  YESNO
- Full Name of Professional Reference*
  
  First NameLast Name
- Place of Employment*
- Position/Relationship*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Number of Years Known*
- Full Name of Professional or Character Reference*
  
  First NameLast Name
- Place of Employment*
- Position/Relationship*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Number of Years Known*
- Full Name of Professional or Character Reference*
  
  First NameLast Name
- Place of Employment*
- Position/Relationship*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Number of Years Known*
- Have you ever pled guilty, no contest or convicted of a crime?*
  
  YESNO
- If YES, in the section below, please disclose all criminal convictions, findings of guilt, pleas of guilty to a misdemeanor or felony charge, any suspended imposition of sentence, any suspended execution of sentence, any period of probation or parole, or pleas of no contest excluding minor traffic offenses. If NO, you must enter N/A.*
- Will you consent to a criminal record check?*
  
  YESNO
- Will you consent to a closed record check?*
  
  YESNO
- Are you currently listed on the EDL (Employee Disqualification List).*
  
  YESNO
- Have you ever used any other names, aliases or social security numbers?*
  
  YESNO
- If you answered YES to using other names, aliases or social security numbers, please list below. If NO, you must enter N/A.*
- Tell us about your caregiving experiences.*
- Check all skills you have experience with:*
  
  COVID-19 Positive ClientAlzheimer's/DementiaTransfer AssistanceGait BeltHoyer/Standing LiftBathing AssistanceTotal Care / Bed Bound ClientIncontinence CareClient Transportation in AutomobileAssistance with Feeding ClientN/AOther
- Check the following you prefer to NOT work with:*
  
  DogsCatsSmokersAlzheimer's/Dementia ClientN/AOther
- Do you have reliable transportation to work?*
  
  YESNO
- How did you hear about us?*
- If you agree to receive electronic communication from Care Solutions In-Home Services LLC, please select your communication preference(s). Check all that apply.*
  
  SMS - Short Messaging ServiceMMS - Multimedia Messaging ServiceEmail MessageI decline electronic communication.
- Please enter your mobile number and/or email address to opt-in for electronic communication.
- By selecting to opt-in to Care Solutions In-Home Services LLC SMS, MMS and email communications, you agree to receive recurring automated promotional and personalized text or email messages from Care Solutions In-Home Services LLC at the mobile number or email used when signing up. Consent is not a condition of any purchase or service. Msg & data rates may apply. Msg frequency varies. You can opt out of our text or email messaging service at any time by replying "STOP" to any message. For assistance, reply "HELP" to any of our messages. Alternatively, you can contact us at office@caresolutionsihs.com. Review our Privacy Policy for more information on how we collect, use, and protect your information.
- I certify that my answers are true and complete to the best of my knowledge. I authorize Care Solutions In-Home Services LLC to make such investigations and inquiries of my personal, employment, educations, and other related matters as may be necessary for an employment decisions. I hereby release employers, schools, or individuals from all liability when responding to inquiries in connection with my application. In the event I am employed, I understand that false or misleading information in my application or interview may result in my release.*
- Today's Date*
  
  MonthDayYear
- I agree to not do business directly with any individual or business entity that Care Solutions In-Home Services LLC has introduced to me or enter into employment agreement with such individuals or business.
- Today's Date
  
  MonthDayYear
- Should be Empty: