Solace Home Care Job Application

JOB APPLICATION
Solace Home Care Service
682 Prospect Ave, Hartford, CT 06105
(860) 483-1348

Solace Home Care Service 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 a reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information Applicant Name: Address:
Applicant Name
City, State and Zip Code: Telephone Number
Address

Address

Street Address Line 2

City, State and Zip CodeState / Province

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

MonthDayYear
Date
Employment Position Position(s) applying for: CNA/HHA (full time)

How did you hear about this position? What days are you available for work?
How did you hear about this position?
What days are you available for work?
What hours or shift are you available for work? If needed, are you available to work overtime? On what date can you start working if you are hired?
What hours or shift are you available for work?
If needed, are you available to work overtime?
On what date can you start working if you are hired?

MonthDayYear
Date
Do you have reliable transportation to and from work?
Have you ever applied to or worked for Solace Home Care Service before?
Yes
If yes, when?
Do you have any friends, relatives, or acquaintances working for Solace Home Care Service If yes, state name & relationship:
Yes
If yes, state name & relationship
Are you 18 years of age or older?
Yes
No
Are you a U.S. citizen or approved to work in the United States?
Yes
No
What document can you provide as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?
Yes
No
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
Yes
No
If yes, please state the nature of the crime(s). when and where convicted and disposition of the case
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may. however, be considered
Please list below the skills and qualifications you possess for the position for which you are applying
(Note: Solace Home Care Service complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.

Vocational School/Specialized Training Name
Name
Year Graduated
Military: Are you a member of the Armed Services?
Are you a member of the Armed Services?
What branch of the military did you enlist?
What was your military rank when discharged? How many years did you serve in the military?
What was your military rank when discharged?
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:
Employer Name
Job Title
Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving
Supervisor Name
Address

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Dates Employed

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

Employer Address

Street Address Line 2

City, State and Zip CodeState / Province

Postal / Zip Code
Reason for leaving
Dates Employed

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

MonthDayYear
Date
Reason for leaving
References Please provide 2 personal and professional reference(s) below:
Reference
The relationship between you and the Solace Home Care Service 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 Solace Home Care Service. No representative of Solace Home Care Service 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.
Applicant Signature

Clear
Dated

MonthDayYear
Date
Should be Empty:

JOB APPLICATION