Specialty Home Care

Specialty Home Care Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, gender, religion, disability, medical condition, national origin, or marital status. Work is scheduled based on client needs and employee availability, with no guarantee of full time employment. Benefits are not guaranteed and are currently limited to a 401(k) retirement plan with voluntary employee contributions and an employer match. Employees may work for other employers, but shift assignments are usually recurring and preference is given to those who commit to regular assignments. We are an AT-WILL employer under Pennsylvania law and the employment relationship may be terminated at any time for any reason, with or without cause or notice. An application is incomplete if any required item is omitted. Completion of all applicable items is strongly recommended. Employment information should be included even if you have supplied a resume. PLEASE NOTE THAT THIS APPLICATION IS NOT COMPATIBLE WITH SOME MOBILE BROWSERS AND YOU MAY ENCOUNTER PROBLEMS COMPLETING THE APPLICATION ON YOUR MOBILE DEVICE. USE OF A COMPUTER IS RECOMMENDED.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

How did you hear about us? (required)

Date Available? (required)

Job Type? (required)

Do you have a valid driver's license? (required)

Yes No

If yes, please enter State and DL # above, and expiration date here:

Has your license ever been suspended or revoked? (required)

Yes No

If yes, please explain

Do you have proof of personal auto insurance? (required)

Yes No

If yes, please give ins. expiration date; if no, please explain:

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Please list any moving violations in the past three years, with date, location and explanation

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Have you lived continuously in PA for the last two years? (required)

Yes No

If #11 is no, do you have an FBI background check report?

Yes No

If #11 is yes, do you have a PA criminal history report less than 12 months old

Yes No

Do you have results from a TB test or x-ray given in the past 12 months? (required)

Yes No

Section 2 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Section 3 - Education

Name and location of High School: (required)

# of years completed

(Numeric Answer Only)

Did you graduate? (required)

Yes No

Additional Education (vocational, undergraduate, graduate or professional, etc.)

Yes No

If yes, please list the name and location of each school, number of years attended and whether you graduated:

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Section 4 - Other Training: Certifications/Licenses

Certifications/Licenses:

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Have you had any Home Care training? What and When?

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Section 5 - Current or most recent Employment

Current (or most recent) Employer: (required)

Address:

City:

State:

Zip Code:

Start Date: (required)

End Date:

Hours Worked:

Position/Title: (required)

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Starting pay

Ending pay

Were you ever disciplined? If so, please explain:

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May we contact?

Yes No

If no, why not:

Section 6 - Employment History

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Starting pay

Ending pay

Reason for Leaving:

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What will your employer say was the reason your employment terminated?

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How much notice did you give if you resigned?

May we contact?

Yes No

If no, why not:

If you have had other employers in the past ten years, provide the same information requested in items 1-19 for each:

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Section 7 - Other Employment Questions

Have you ever been terminated or asked to resign from any job? (required)

Yes No

If yes, how many times?

(Numeric Answer Only)

If yes, please explain the circumstances of each occasion:

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Section 8 - Reference 1 (Employer or unrelated individual)

Name: (required)

Phone: (required)

Relationship

Section 9 - Reference 2 (Employer or unrelated individual)

Name: (required)

Phone: (required)

Relationship

Section 10 - Work Availability (Note: work periods vary)

Monday availability (indicate times) (required)

Tuesday availability (indicate times) (required)

Wednesday availability (indicate times) (required)

Thursday availability (indicate times) (required)

Friday availability (indicate times) (required)

Saturday availability (indicate times) (required)

Sunday availability (indicate times) (required)

Interested in Overnights? (typically 9pm - 7am) (required)

Yes No

Please give additional details about your availability if needed

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Section 11 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above. I authorize and consent to, without reservation, any background check, driving record check or any other review permitted or required by federal, state and/or local law, and to complete any requisite authorization forms which may be necessary for this purpose. I authorize and consent to any party or agency contacted by this employer to furnish the above information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state and local law, any party delivering such information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which i may have as a result of the delivery or disclosure of the requested information. i hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, i authorize the Company to provide truthful information concerning my employment to future employers and hold the Company harmless for providing it. i understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, i may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.

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