Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Social Security Number
*
If hired, can you furnish proof you are eligible to work in the U.S.?
*
Yes
No
Today's Date
*
MM
DD
YYYY
What position are you applying?
*
Are you seeking:
*
When could you start work?
*
MM
DD
YYYY
Have you ever applied here before?
*
Yes
No
Is yes, when?
Were you ever employed here?
*
Yes
No
If yes, when?
Have you ever been convicted of any law violation (except a minor traffic violation)?
*
Yes
No
If yes, give details.
(A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.)
Are you now or do you expect to be engaged in any other business or employment?
*
Yes
No
If yes, please explain.
Do you have a valid driver's license?
*
Yes
Now
Have you had your driver’s license suspended or revoked in the last 3 years?
*
Yes
No
If yes, give details.
List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal age over 40, race, sex, color, religion, national origin, disability or other protected status.)
Name of High School or GED
*
Address of High School or GED
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Diploma/Degree/Certificate Received?
Name of College or University
Address of College or University
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Diploma/Degree/Certificate Received?
Name of Vocational or Technical School
Address of Vocational or Technical School
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Diploma/Degree/Certificate Received?
What skills or additional training do you have that are related to the job for which you are applying?
*
Address (Employer 1)
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (Employer 1)
(###)
###
####
Job Title and Duties (Employer 1)
Dates of Employment (Employer 1)
Ending Pay (Employer 1)
Reason for Leaving (Employer 1)
Employer 2
Address (Employer 2)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (Employer 2)
(###)
###
####
Job Title and Duties (Employer 2)
Dates of Employment (Employer 2)
Ending Pay (Employer 2)
Reason for Leaving (Employer 2)
Employer 3
Address (Employer 3)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (Employer 3)
(###)
###
####
Job Title and Duties (Employer 3)
Dates of Employment (Employer 3)
Ending Pay (Employer 3)
Reason for Leaving (Employer 3)
Have you worked or attended school under any other name?
*
Yes
No
If yes, give names.
Are you presently employed?
*
Yes
No
If yes, may we contact your present employer?
Have you ever been fired from a job or asked to resign?
*
Yes
No
If yes, please explain.
Give three references, not relatives or former employers.
*
Name, job title, company, email address, and phone number.
Please provide the following information on your availability to work for Graceful In Home Care, LLC..
*
Type of Transportation you have / will use for home visits
Do you have any allergies that would affect your work?
*
Yes
No
If yes, please list here.
Do you have a problem working with a client who smokes?
*
Yes
No
How many hours are you willing to work per week?
*
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
*
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment
and may result in my dismissal if discovered at a later date.
I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal
characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for
the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.
I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations
named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organization from any legal liability in making such
statements.
I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all
medical information as may be deemed necessary to judge my capability to do the work for which I am applying.
I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required.
I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD
OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read, understand, and by my signature consent to these statements.
