Start Your Career in Our Home and Personal Care Agency FUTURE AT HOME CARE LLC EMPLOYMENT APPLICATION All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential. PERSONAL Last Name First Name Middle Date MM slash DD slash YYYY Street Address Home PhoneCity State Zip Code Business PhoneEmergency contact (person not living with you)Have you ever applied for employment with this Agency? Yes No How many hours a week are you available for work? Are you legally eligible for employment in the United States? Yes No How did you learn of our organization? Online Ad Agency employee Other Are you willing to work: Evenings? Weekends? Position applying for: EDUCATION: School Name Degree/Diploma College: Location of School Course of Study Vo-Tech or Trade: High School: Other: Employment: List the last five years employment history, starting with the most recent employer. 1. Company Name: Telephone:Address: Dates of Employment: From MM slash DD slash YYYY To MM slash DD slash YYYY City State Zip Code Starting Pay: Job Title and Describe your work: Reason for leaving: 2. Company Name: Telephone:Address: Dates of Employment: From MM slash DD slash YYYY To MM slash DD slash YYYY City State Zip Code Starting Pay: Job Title and Describe your work: Reason for leaving: 3. Company Name: Telephone:Address: Dates of Employment: From MM slash DD slash YYYY To MM slash DD slash YYYY City State Zip Code Starting Pay: Job Title and Describe your work: Reason for leaving: Was your last name different from your present name during the above listed jobs? Yes No If yes, what was your name? Are you currently employed? Yes No Do you have reliable transportation? Yes No PROFESSIONAL REFERENCES Persons who can furnish information about job performance 1. Name: Telephone:Address : 2. Name: Telephone :Address: 3. Name: Telephone :Address: GENERAL Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency? Yes No Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:Are you capable of performing the job set forth in the job description? Yes No If you answered No, which job requirement can you not meet? CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience. PLEASE READ ALL STATEMENTS BELOW BEFORE SIGNING THIS APPLICATION: I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSALI Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application I agree to submit to random drug screening as requested. I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.DATE MM slash DD slash YYYY SIGNATUREMax. file size: 100 MB.
