Application for Employment

1
Personal Information
2
Employment
3
Education
4
Work Experience
5
Referees

1/5

Personal Information

Asterisks sign ( * ) means the field must be filled

Personal Information

Last Name*

First Name*

Middle Name

Present Address*

City*

State*

Zip*

How long at current address?*

Social Security No.*

Telephone*

Secondary Telephone

Email Address*

Asterisks sign ( * ) means the field must be filled

Employment

Desired Position Applying for*

How many hours can you work weekly?*

Can you work evenings?*

Days / Hours available to work

Monday

From

Tuesday

From

Wednesday

From

Thursday

From

Friday

From

Saturday

From

Sunday

From

Emplyoment (Select the one that applies) *

When are you available to start work? *

Asterisks sign ( * ) means the field must be filled

Education

Highest Level of Education

Name and Location *

Years Attended*

Date Graduated*

Diploma / Degree / or Certificate *

Type of License/Certificate held *

Other type of Licence/Certificate

License Certificate #

Issuing Authority / Board*

Expiration Date*

Are you CPR Certified? *

Do you have a drivers License?*

Do you have access to a car? *

Are you First Aid Certified? *

Do you have experience with any of the following?*

If Other which one?

Are you Currently Employed? *

Are you a member of the National Guard? *

Did you complete this application yourself? *

If not, who?

Have you been in the armed forces? *

If Yes, Branch?

If Yes, Discarge Date

What other Certificates do you have related to Home Health Care?

Language Spoken*

Asterisks sign ( * ) means the field must be filled

Work Experience

Please list the names and addresses of all institutions, patients, and agencies that you have worked for within the last year (365 days) proceeding the date of application. If more that four (4), please attach additional sheets.

Work 1

Name of Employer

Address

Phone Number

City

State

Zip Code

Name of Last Supervisor

Employment Dates

Last Job Title

Last Hourly Pay or Salary $

Reasons for leaving?

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Work 2

Name of Employer

Address

Phone Number

City

State

Zip Code

Name of Last Supervisor

Employment Dates

Last Job Title

Last Pay or Salary $

Reasons for leaving?

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Work 3

Name of Employer

Address

Phone Number

City

State

City

Name of Last Supervisor

Employment Dates

Last Job Title

Last Pay or Salary $

Reasons for leaving?

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

Work 4

Name of Employer

Address

Phone Number

City

State

Zip Code

Name of Last Supervisor

Employment Dates

Last Job Title

Last Pay or Salary $

Reasons for leaving?

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company

If more than Four (4) positions held, please attach additional sheet(s) - 10MB Max

May we contact your present employer? *

Have you been convicted of a felony? *

If yes, explain number of convictions(s), nature of offence(s),nature of conviction (Be as specific as possible)?

Have you ever been employed with this company? *

If yes, when?

Do you have any friends employed by this company? *

If yes, please provide their name(s) and relationship to you

if hired, would you have a reliable means of transportation to and from work? *

Are you able to perform the essential functions and duties of the job for which you are appying? *

If no, please describe the functions or duties you are unable to perform

If hired, can you provide proof of US citizenship? *

If no, can you provide proof of your legal right to live and work in this country? *

Asterisks sign ( * ) means the field must be filled

References

Please list atleast three (3) persons NOT related to you who have knowledge of your work performance and/or personal qualifications within the last five (5) years.

Reference 1

Reference Name*

Company Name*

Telephone Number*

Years acquainted*

Email (Optional)

Reference 2

Reference Name*

Company Name*

Telephone Number*

Years acquainted*

Email (Optional)

Reference 3

Reference Name*

Company Name*

Telephone Number*

Years acquainted*

Email (Optional)

Application form Waiver

Please read each paragraph closely and accept the terms below by checking the terms box before submitting this application.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances of employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have completed this application. I understand that any omission or misstatement of material fact on this application or any other document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize Best Care Home Agency (LLC) to thoroughly investigate my references,work records, education, driving record, credit history, criminal background, and other matters relating to my suitability for employment. I further authorize the employers, schools and other references I have listed to disclose to Best Care Home Agency (LLC) any and all documents, transcripts, letters, reports and other information related to the references, without giving me prior notice of such disclosure. I hereby release Best Care Home Agency (LLC), my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosures.

I understands that nothing contained in the application, or conveyed during any interview which may be granted, or during my employment, if hired, is intended to create an employment contract between me and Best Care Home Agency (LLC), other than that is "At Will" nature, whereby either the employee or employer may terminate the employment relationship any time, with or without cause or notice. I further understand that my employment, if hired, in no definite or determinable period of time and may be terminated at any time, at the option or either myself or Best Care Home Agency (LLC), and that no promise or representation contrary to the foregoing is binding on the company unless made in writing and signed by me and the company designated representative.

EEO Statement
Best Care Home Agency (LLC) is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with Best Care Home Agency (LLC) depends solely on your qualifications.
Non Discrimination Statement In accordance with our non discrimination policy, Best Care Home Agency (LLC) will make every reasonable accommodation to provide for disabled or handicapped employees.

I agree with the Terms above

Optional, Select all that apply

Personal Information

Employment

Days / Hours available to work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Education

Highest Level of Education

Work Experience

Work 1

Work 2

Work 3

Work 4

References

Reference 1

Reference 2

Reference 3

Application form Waiver

Working Hours

Insurance ACCEPTED

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