Employment Application
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of gender, marital status, pregnancy, religion, race, age, creed, national origin, presence of disabilities, sexual orientation, genetic screening or testing information, refusal to submit to a genetic test, ancestry, AIDS or HIV status, and on any other status protected by law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.
Today's Date
Social Security#
Name
Current Address
Previous Address
Home Phone#
Work Phone#
Mobile Phone#
Email
(valid email required)
Emergency Contact
Valid Driver's License#
State Issued
Exp. Date
Make & Year of Vehicle
Auto Insurance Company
Policy#
Auto Insurance Agent
Phone#
How did you hear about Home Instead Senior Care?
Why are you interested in employment with Home Instead Senior Care?
AVAILABILITY
Please indicate the type(s) of work that you would prefer (Use CTRL to select multiple options)
Full-Time
Part-Time
Days
Evenings
Overnights
Live-In
Approximately how many hours per week do you wish to work?
When are you available to begin work?
Would you accept long-term assignments?
Yes
No
Would you accept short-term assignments?
Yes
No
Please indicate the days and times that you are available for work
The following services are job functions, however, not limited to, of our CAREGivers: Meal Preparation, WalkingStanding Assistance, Dressing Assistance, Shower Assistance, Safety Precautions, Laundry, Medication Reminders, Transportation, Running Errands, Light Housecleaning
Do you have any reservations about providing service to a client with a pet(s)?
Yes
No
If Yes, what types of pets?
Would it bother you to provide service to a client that smokes?
Yes
No
We operate in a geographical area that encompasses Scottsdale, Phoenix, Carefree, Peoria, Glendale, and the Sun Cities; it is an expectation as our employee that all clients are staffed, regardless of location. All efforts are made to allow you to assist clients within a reasonable distance of your home.
EDUCATION
Please indicate highest grade completed
Grade School
6
7
8
High School
9
10
11
12
College
13
14
15
16
16+
High School
Name of School, City/State, Major Subject, # of Yrs. Attended, Did You Graduate?
Vocational
Name of School, City/State, Major Subject, # of Yrs. Attended, Did You Graduate?
College/University
Name of School, City/State, Major Subject, # of Yrs. Attended, Did You Graduate?
Other
Name of School, City/State, Major Subject, # of Yrs. Attended, Did You Graduate?
SECURITY
As a condition of employment all employees must be "Bondable".
List states and counties of residence for the past seven years
Have you had any moving traffic violations?
Yes
No
If Yes, please describe
Have you used any names or Social Security Numbers other than those on this application?
Yes
No
If Yes, please list
Have you been convicted of a felony and/or misdemeanor?
Yes
No
If Yes, please describe incidents
JOB RELATED SKILLS
Note: Do not fill out any part of this section if you believe it to be non-job related.
Describe any training you have had that applies to service and/or care for elderly.
Describe any work history applicable to Elderly Service and Care.
What do you like (or think you would like) about working with older adults?
What do you like (or think you would like) least about working with older adults?
PERSONAL REFERENCES (Do not include relatives)
Reference #1
Full Name, Address, Phone#, Time of Day to Call, Relationship, # of Years Known
Reference #2
Full Name, Address, Phone#, Time of Day to Call, Relationship, # of Years Known
Reference #3
Full Name, Address, Phone#, Time of Day to Call, Relationship, # of Years Known
Reference #4
Full Name, Address, Phone#, Time of Day to Call, Relationship, # of Years Known
Reference #5
Full Name, Address, Phone#, Time of Day to Call, Relationship, # of Years Known
Reference #6
Full Name, Address, Phone#, Time of Day to Call, Relationship, # of Years Known
EMPLOYMENT REFERENCES
Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.
Most Recent Employer
Are you currently working for this employer?
If Yes, may we contact?
Company Name
City/State
Phone Number
Dates Employed
Job Title
Supervisor's Name
Duties
Salary
Reason For Leaving
Second Most Recent Employer
Company Name
City/State
Phone Number
Dates Employed
Job Title
Supervisor's Name
Duties
Salary
Reason For Leaving
Third Most Recent Employer
Company Name
City/State
Phone Number
Dates Employed
Job Title
Supervisor's Name
Duties
Salary
Reason For Leaving
COMMENTS
Give us your input
CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on 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 understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application and discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal 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 the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs to and during employment.
Signature
Date
CC Me
At Home Assistance Inc. d.b.a. Home Instead Senior Care. Each office is independently owned and operated.
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