JOB APPLICATION

JOB APPLICATION
Quality Senior Home care & Staffing

843 Parkman Rd NW, Warren, Ohio 44485

330-333-2006

Quality Senior Home Care & Staffing is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:
Applicant Name
Address

Address

Street Address Line 2

City State and Zip CodeState / Province

Postal / Zip Code
Telephone Number
Email Address
example@example.com
Date of Application

MonthDayYear
Date
Employment Position: please type Home health
Employment Position Position(s) applying for: Home Health aid
How did you hear about this position
What hours or shift are you available for work
On what date can you start working if you are hired

MonthDayYear
Date
What days are you available for work
Do you have reliable transportation to and from work
Salary desired
If yes when
Do you have any friends friends,relative or acquaintances working for Quality Senior Home care And staffing ? If yes state name relationship if no put N/A
Are you 18 years of age or older?

YesNO
Are you a US Citizen or approved to work in the United States?

YesNo
What document can you provide as proof of citizenship or legal status
Will you consent to a mandatory controlled substance test?

YesNo
Have you ever applied to or worked for Quality Senior Home care & Staffing before?

yesno
Do you have any condition which would require job accommodations?

YesNO
If yes please describe accommodations required below
Have you ever been convicted of a criminal offense (felony or misdemeanor)?

YesNO
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:
Please list below the skills and qualifications you possess for the position for which you are applying:
Job Skills/Qualifications
(Note: Quality Senior Home care & Staffing complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional
Education and Training Name of High School
Location City State
Year Graduated
Degree Earned
Name
Location City State
Degree Earned
Vocational School/Specialized Training Name
Name
Location City State
Year Graduated
Degree Earned
Year Graduated
Are you a member of the Armed Services
What was your military rank when discharged
What branch of the military did you enlist
How many years did you serve in the military
What military skills do you possess that would be an asset for this position
Previous Employment Employer Name: Job Title:
1. Employer Name
Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving
Supervisor Name
Job Title
Address

Employer Address

Street Address Line 2

City State and Zip CodeState / Province

Postal / Zip Code
If needed are you available to work overtime
Dates Employed

MonthDayYear
Date
Reason for leaving
2. Employer Name
Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving
Job Title
Supervisor Name
Employer Address
City State and Zip Code
Dates Employed

MonthDayYear
Date
Reason for leaving
Job Title
3. Employer Name
Supervisor Name
Employer Address: City, State and Zip Code:
Address

Employer Address

Street Address Line 2

City State and Zip CodeState / Province

Postal / Zip Code
Employer Telephone: Dates Employed: Reason for leaving
Dates Employed

MonthDayYear
Date
Reason for leaving

References Please provide 3 personal and professional reference(s) below:

	Name	Contact inofrmation
Reference 1
Reference 2
Reference 3

AT-WILL EMPLOYMENT

The relationship between you and the Quality Senior Home care & Staffing is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Quality Senior Home care & Staffing. No representative of Quality Senior Home care & Staffing has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.
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